A nurse is assessing the peripheral IV site of a client who is receiving dopamine. The site is edematous and cool to the touch, and the client reports pain in that area. After disconnecting the administration set, which of the following actions should the nurse take next?
Apply a cold compress to the affected areas of the IV site.
Aspirate the remaining medication from the catheter port with a syringe.
Inject phentolamine into the areas that are edematous.
Take a photograph of the IV site.
The Correct Answer is B
Rationale:
A. Apply a cold compress to the affected areas of the IV site: Cold compresses are not recommended for dopamine extravasation, as they can worsen vasoconstriction. Warm compresses or antidote administration are preferred to promote vasodilation.
B. Aspirate the remaining medication from the catheter port with a syringe: The priority after stopping the infusion is to aspirate as much of the vesicant drug as possible to limit tissue damage. This action helps prevent further injury from the extravasated dopamine.
C. Inject phentolamine into the areas that are edematous: Phentolamine is the antidote for dopamine extravasation, but it should be administered only after aspiration of the drug. Aspiration reduces the drug concentration before antidote infiltration.
D. Take a photograph of the IV site: Documentation may be useful later for quality reporting, but it is not a priority action. Immediate steps to reduce tissue damage must be taken first before photographic evidence is gathered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Ask the client if she is receiving her pain medication: While assessing the client’s experience with pain management is appropriate, this step does not directly address the suspicious behavior or fulfill the nurse’s professional obligation to report potential substance misuse.
B. Assume care of the nurse's clients: Taking over client care without reporting the issue does not resolve the potential safety concern. It also may be outside the observing nurse’s authority or capacity, and it avoids confronting the root problem.
C. Report the nurse's behavior to a charge nurse: Reporting the observed behavior to a supervisor is the appropriate first action. It allows the situation to be formally investigated and ensures that client safety and professional accountability are maintained.
D. Confront the nurse about the situation: Confronting a colleague suspected of substance misuse can escalate the situation and may be unsafe. It bypasses institutional reporting protocols and may place the observing nurse at risk personally or professionally.
Correct Answer is B
Explanation
Rationale:
A. Sending out written surveys to community members over the age of 50: This method involves direct input from residents and is useful for targeted data collection, but it is not part of a windshield survey, which relies on direct environmental observation.
B. Travelling through the community neighborhoods for visual observations: A windshield survey involves driving or walking through an area to make observations about housing, resources, infrastructure, and visible health risks. It provides firsthand, contextual insight into the community environment.
C. Holding a community meeting to gather information: Community meetings are effective for engaging stakeholders and collecting qualitative data, but they are not part of the observational method used in a windshield survey.
D. Researching national statics on disease outbreaks among adolescents: While useful for broader epidemiological insight, national statistics are not specific to the local community and are not obtained through a windshield survey approach.
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