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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Morphine 6 mg IV push every 3 hr PRN acute pain:
This choice is correct. It accurately transcribes the medication name (morphine), the dosage (6 mg), the route (IV push), the frequency (every 3 hours), and the indication (PRN for acute pain).
B. Morphine 6.0 mg IV push every 3 hr PRN acute pain:
This choice is not incorrect, but it is unnecessary to include the trailing zero in the dosage (6.0 mg). Both "6" and "6.0" indicate the same value, and omitting the decimal point is common practice in medication dosages.
C. MS 6 mg IV push every 3 hr PRN acute pain:
This choice is incorrect. "MS" is an abbreviation for "morphine sulfate," but it's not widely used in modern healthcare settings. Using the full name "morphine" is clearer and less prone to confusion.
D. MSO4 6 mg IV push every 3 hr PRN acute pain:
This choice is incorrect. "MSO4" is the chemical symbol for morphine sulfate. While it's a valid abbreviation, it's not as commonly used as the full name "morphine." Using the full name of the medication is clearer and more familiar to healthcare professionals.

A. The client has a negative sputum culture. B. The client tests negative for HIV. C. The client's liver function test results are within the expected reference range. D. The client has a positive purified protein derivative test

Correct Answer is A

Explanation

A. The client has a negative sputum culture.
When a client with tuberculosis is adhering to the prescribed medication regimen, their sputum cultures should show a decrease in the number of Mycobacterium tuberculosis bacteria. This indicates that the medication is effectively treating the infection. It's important for clients with tuberculosis to complete their full course of treatment to prevent drug-resistant strains of the bacteria from developing.
B. The client tests negative for HIV: This relates to a different infection (HIV) and doesn't necessarily reflect adherence to the tuberculosis medication regimen.
C. The client's liver function test results are within the expected reference range: While liver function tests are important to monitor due to potential medication side effects, they don't directly indicate medication adherence.
D. The client has a positive purified protein derivative (PPD) test: A positive PPD test indicates exposure to the tuberculosis bacteria in the past but does not reflect current adherence to treatment.

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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?

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