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 D
Explanation
The correct answer is d
Choice A reason:
Administering filgrastim 12 hours after chemotherapy does not typically require an incident report. Filgrastim is often given at least 24 hours after chemotherapy to avoid the risk of increasing the toxicity of the chemotherapy agents. While the timing is closer than recommended, it does not necessarily constitute an error unless specific instructions for the timing were provided by the prescribing physician.
Choice B reason:
The medication vial sitting at room temperature for 2 hours before administration does not require an incident report. Filgrastim can be left out at room temperature for up to 24 hours before use. This is within the safe handling guidelines for the medication.
Choice C reason:
An absolute neutrophil count (ANC) of 2,500/mm³ is within the normal range, which is typically 1,500-8,000/mm³. Filgrastim is used to increase neutrophil counts in patients with low ANC due to chemotherapy. Since the ANC was not low before administration, this would not necessitate an incident report, although it may prompt a review of the necessity of the medication.
Choice D reason:
Flushing the client's IV line with dextrose 5% in water before and after the medication was administered is not the standard procedure and could potentially lead to medication errors or adverse effects. Filgrastim should be diluted in glucose 5% in water for intravenous infusion, but not used to flush the line. This deviation from the standard protocol is what necessitates an incident report.
Correct Answer is D
Explanation
Saw palmetto is a natural herbal supplement that may help reduce the symptoms of benign prostate hypertrophy (BPH) by inhibiting the enzyme 5- alpha-reductase, which converts testosterone to dihydrotestosterone (DHT), a hormone that stimulates prostate growth. Some studies have shown that saw palmetto can improve urinary flow and reduce nocturia in men with BPH.
Choice Ais wrong because black cohosh is a plant that contains phytoestrogens, which are compounds that mimic estrogen in the body.Black cohosh is mainly used for menopausal symptoms in women, such as hot flashes and mood swings.
Choice Bis wrong because garlic has no proven effect on BPH. Garlic may have some benefits for cardiovascular health and immune system, but it does not affect prostate size or function.It has no effect on BPH and may even worsen it by altering the hormonal balance.
Choice C is wrong because feverfew is a herb that has anti-inflammatory and anti-migraine properties.
It may help prevent or treat headaches, arthritis, and allergies, but it has no effect on BPH or urinary symptoms.
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