A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?
Apply a warm, moist compress.
Slow the IV solution rate.
Initiate a new IV distal to the initial site.
Maintain the extremity below the level of the heart
The Correct Answer is A
A. Apply a warm, moist compress.
Explanation:
A cool and edematous IV infusion site could indicate infiltration of the IV site, which occurs when the IV fluid leaks into the surrounding tissue instead of entering the bloodstream. Applying a warm, moist compress to the site can help improve blood circulation and reduce the discomfort associated with infiltration. This action can also help reduce tissue damage.
B. Slow the IV solution rate: Slowing the IV solution rate might not be effective in resolving the infiltration. It's important to address the infiltration itself rather than just adjusting the rate of infusion.
C. Initiate a new IV distal to the initial site: While starting a new IV site might be necessary if the current site cannot be salvaged, it's not the initial action to take. Applying warm, moist compresses and assessing the severity of the infiltration are appropriate steps before considering a new IV site.
D. Maintain the extremity below the level of the heart: Elevating the extremity could help reduce swelling in some cases, but it's not the primary action to take when dealing with IV infiltration.
Remember, prompt assessment and appropriate interventions are essential to prevent complications associated with IV infiltration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased blood pressure:
An elevated aPTT (activated partial thromboplastin time) suggests that the client is receiving heparin therapy. Heparin is an anticoagulant that prevents blood clotting. It's not likely to cause a significant increase in blood pressure directly. Changes in blood pressure may occur due to other factors, but they are not directly related to heparin therapy.
B. Decreased temperature:
Heparin administration does not typically have a direct effect on body temperature. Changes in body temperature might be due to other factors such as infection, but they are not a primary consideration when assessing the effects of heparin therapy.
C. Decreased respiratory rate:
Heparin administration is not known to directly affect respiratory rate. Changes in respiratory rate could be related to respiratory conditions, pain, or other factors unrelated to heparin therapy.
D. Increased pulse rate:
This is the correct choice. Heparin is known to affect the clotting process by inhibiting clot formation. An extended aPTT of 90 seconds indicates that the client's blood is taking longer to form clots than the normal range. This could lead to concerns about potential bleeding complications. Increased pulse rate could be an early sign of bleeding or decreased perfusion, as the body may attempt to compensate for reduced blood volume due to prolonged clotting times.
Correct Answer is A
Explanation
A. Estrogen-progestin combination:
Correct Answer: This medication interacts with carbamazepine.
Explanation: Carbamazepine is known to induce certain liver enzymes, including cytochrome P450 enzymes. These enzymes play a role in the metabolism of various medications, including estrogen-containing oral contraceptives (estrogen-progestin combinations). Carbamazepine can increase the metabolism of estrogen-progestin combinations, potentially reducing their effectiveness and increasing the risk of contraceptive failure. Therefore, this interaction can lead to decreased contraceptive efficacy and the potential for unintended pregnancy.
B. Nicotine transdermal system:
Incorrect Explanation: This medication does not interact with carbamazepine.
Explanation: Nicotine replacement therapies, such as nicotine transdermal systems, are not known to have significant interactions with carbamazepine. These therapies are primarily used to aid in smoking cessation and do not share metabolic pathways with carbamazepine.
C. Diphenhydramine:
Incorrect Explanation: This medication does not interact with carbamazepine.
Explanation: Diphenhydramine is an antihistamine used for allergies and as a sleep aid. It does not have a well-established interaction with carbamazepine. However, it's important to note that carbamazepine can have central nervous system (CNS) effects, so caution should be exercised when combining it with other medications that also have CNS effects.
D. Beclomethasone:
Incorrect Explanation: This medication does not interact with carbamazepine.
Explanation: Beclomethasone is a corticosteroid used to manage inflammation associated with conditions like asthma and allergic rhinitis. It is not known to interact with carbamazepine. These two medications have different mechanisms of action and do not share significant metabolic pathways.
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