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","E"]
Explanation
D. Persistent headache can occur with elevated levels of gentamicin, as it may indicate neurotoxicity. Gentamicin can cause neurotoxic effects, including headaches, especially when levels are elevated.
E. Tinnitus (ringing in the ears) is a classic symptom of gentamicin toxicity. Elevated gentamicin levels can lead to ototoxicity, which manifests as tinnitus among other auditory symptoms.
A. Insomnia is not typically associated with elevated levels of gentamicin. Elevated gentamicin levels are not known to cause insomnia.
B. Constipation is not typically associated with elevated levels of gentamicin. Elevated gentamicin levels are not known to cause constipation.
C. Xerostomia (dry mouth) is not typically associated with elevated levels of gentamicin. Elevated gentamicin levels are not known to cause xerostomia.
Correct Answer is ["A","B","D"]
Explanation
A. Streak formation along the vein is a characteristic sign of phlebitis. It indicates inflammation and possibly thrombophlebitis (inflammation with clot formation) within the vein.
B. Erythema (redness) at the insertion site is a common early sign of phlebitis. It indicates localized inflammation of the vein.
C. Blistering around the insertion site is not typically associated with phlebitis. It may suggest a severe reaction or infection, but it is not a common manifestation of phlebitis itself.
D. Warmth at the insertion site is a common sign of inflammation, including phlebitis. It indicates increased blood flow and localized inflammatory response.
E. A damp dressing over the insertion site can contribute to the risk of infection but is not a direct manifestation of phlebitis. However, it can be a contributing factor to the development of phlebitis if moisture leads to skin breakdown or infection.
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