A nurse identifies an extravasation of a vesicant solution at a client's peripheral IV catheter's insertion site. Identify the sequence in which the nurse should perform the following actions.
(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Disconnect the tubing from the catheter.
Remove the IV catheter.
Aspirate the solution from the catheter.
Stop the infusion.
Attach a syringe to the catheter.
The Correct Answer is D,A,E,C,B
The nurse should first stop the infusion (D) to prevent further infiltration of the vesicant solution. Next, the nurse should attach a syringe to the catheter (E) to prepare for aspiration.
Following this, the nurse should aspirate the solution from the catheter (C) to remove as much of the vesicant as possible. After aspiration, the nurse should disconnect the tubing from the catheter (A), ensuring that no additional vesicant is administered. Finally, the nurse should remove the IV catheter (B) to prevent any further exposure to the vesicant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Tachycardia refers to an elevated heart rate. In circulatory overload, the heart may attempt to compensate for the increased fluid volume by pumping faster. This compensatory mechanism aims to maintain adequate tissue perfusion despite the excessive fluid burden.
A. Diaphoresis refers to excessive sweating. It is not typically associated with circulatory overload. Instead, diaphoresis can occur in conditions such as fever, anxiety, or during physical exertion.
B Hypotension refers to low blood pressure. In circulatory overload, the excess fluid in the circulatory system can lead to increased blood pressure rather than hypotension. Hypotension is more commonly associated with hypovolemia (low blood volume) rather than hypervolemia.
C. Weight loss is not a characteristic finding in circulatory overload. On the contrary, patients with fluid overload often experience weight gain due to retained fluid in the body tissues and bloodstream.
Correct Answer is A
Explanation
A. Distal veins, such as those in the hand or forearm of the nondominant arm, are often preferred for initial IV placement. These veins are typically smaller but can be easier to access and cause less discomfort for the patient compared to more proximal veins.
B. Proximal veins, such as those in the upper arm (brachial or basilic veins), may be considered if distal veins are not accessible or suitable. However, proximal veins are larger and can be more difficult to cannulate, potentially causing more discomfort and increasing the risk of complications.
C. The antecubital veins, located in the bend of the elbow, are commonly used for venipuncture due to their accessibility and size. The antecubital vein of the nondominant arm is often preferred to minimize interference with the patient's daily activities and reduce the risk of complications associated with frequent use of the dominant arm.
D. While the antecubital vein of the dominant arm may also be accessible, it is generally recommended to preserve this area for procedures that require a higher level of dexterity and strength. Frequent venipuncture in the dominant arm can lead to discomfort and potential complications, such as phlebitis or thrombosis.
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