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?
Initiate a new IV distal to the initial site.
Slow the IV solution rate.
Maintain the extremity below the level of the heart.
Apply a warm, moist compress.
The Correct Answer is D
The most appropriate action for the nurse to take in this situation is:
d. Apply a warm, moist compress.
Here's why the other options are not recommended:
- a. Initiate a new IV distal to the initial site: This is not the first course of action. While starting a new IV might be necessary eventually, it's crucial to address the issue at the current site first.
- b. Slow the IV solution rate: Slowing the rate doesn't directly address the coolness and edema, which indicate potential infiltration or extravasation.
- c. Maintain the extremity below the level of the heart: This action would actually worsen the edema by promoting fluid accumulation at the site.
Applying a warm, moist compress can help promote absorption of any leaked fluid and improve circulation at the site. However, it's important to remember that this is just one step in the process. The nurse should also:
- Stop the IV infusion.
- Assess the extent of the infiltration or extravasation.
- Document the findings.
- Elevate the affected extremity.
- Consult with a physician for further instructions and potential treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Lithium can cause hyponatremia by increasing the secretion of antidiuretic hormone and reducing the renal clearance of sodium.
Strenuous exercise can also cause hyponatremia by increasing sweat loss and fluid intake. Therefore, a client who is taking lithium and starting a new exercise program is at risk of developing hyponatremia.
Choice A is wrong because hypomagnesemia is not a common side effect of lithium or exercise.
Choice B is wrong because hypocalcemia is not a common side effect of lithium or exercise.
Choice D is wrong because hypokalemia is not a common side effect of lithium or exercise.
However, lithium can interact with some diuretics that can cause hypokalemia, so the client should avoid taking these drugs without consulting their doctor. Normal ranges for electrolytes are:
Sodium: 135-145 mmol/L
Magnesium: 0.7-1.1 mmol/L
Calcium: 2.1-2.6 mmol/L
Potassium: 3.5-5.0 mmol/L
Correct Answer is B
Explanation
Gastric bleeding can occur due to peptic ulcer disease, nonsteroidal anti inflammatory drugs (NSAIDs), or anticoagulants.
Choice C is wrong because cough is not a common adverse effect of morphine administered via continuous epidural infusion.
Cough can be caused by respiratory infections, asthma, or chronic obstructive pulmonary disease (COPD).
Choice D is wrong because tachypnea is not a common adverse effect of morphine administered via continuous epidural infusion.
Tachypnea can be caused by hypoxia, anxiety, pain, or fever. Morphine can cause respiratory depression, which is characterized by bradypnea, not tachypnea.
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