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 ["125"]
Explanation
To calculate the rate at which the IV pump should be set to deliver the prescribed volume of intravenous fluids,
Divide the total volume of fluids (3,000 mL) by the number of hours over which they are to be administered (24 hours). This calculation gives you 125 mL/hr.
Therefore, the nurse should set the IV pump to deliver 125 mL of fluid per hour to meet the 24-hour requirement.
Correct Answer is D
Explanation
D. Administering the injection in the love handles, 2 inches from the umbilicus. It is important not to remove the air bubble from the prefilled syringe, as it is designed to ensure the entire dose of medication is administered.
A. Enoxaparin should not be transferred into another syringe unless specifically instructed by the manufacturer or pharmacy guidelines. Pre-filled syringes are designed to deliver the correct dose accurately and safely.
B. It is important not to remove the air bubble from the prefilled syringe, as it is designed to ensure the entire dose of medication is administered.
C. A 30-degree angle is too shallow for subcutaneous injections and may result in the medication being deposited too close to the skin surface, potentially causing irritation or affecting absorption.
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