A nurse is assisting with the care of a client who has pneumonia.
For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
Administer phytonadione.
Apply cool compress to the extremity.
Elevate extremity.
Suggest irrigating the IV catheter
Assist in inserting a new IV catheter in a site distal to infiltration site
Send the catheter tip for culture.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"}}
Administer phytonadione (Vitamin K): Contraindicated
There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition.
Apply cool compress to the extremity: Anticipated
A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues.
Elevate extremity: Anticipated
Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery.
Suggest irrigating the IV catheter: Contraindicated
Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately.
Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated
A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration.
Send the catheter tip for culture: Anticipated
Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Steatotic liver disease: Steatotic liver disease, or fatty liver disease, is typically associated with excess fat in the liver, often linked to alcohol use, obesity, or diabetes. While it can affect liver function, it is not primarily associated with deficiencies in iron and vitamin B12. Therefore, this condition is not directly related to the lab findings of low iron and vitamin B12.
B) Leukemia: Leukemia is a type of cancer that affects the blood and bone marrow, leading to abnormal white blood cell production. While leukemia can cause anemia as a secondary effect due to bone marrow dysfunction, it is not typically characterized by deficiencies in both iron and vitamin B12 simultaneously. The lab findings are more consistent with a nutritional or absorption issue rather than leukemia.
C) Hepatitis: Hepatitis refers to inflammation of the liver, usually caused by a viral infection or other factors. While hepatitis can lead to various blood abnormalities, it is not specifically linked to both iron and vitamin B12 deficiencies. Hepatitis more commonly affects liver function and may cause jaundice, but it does not directly explain low iron and B12 levels.
D) Anemia: Both iron and vitamin B12 are essential for the production of healthy red blood cells. Iron deficiency can lead to iron-deficiency anemia, and vitamin B12 deficiency can cause pernicious anemia. Therefore, low levels of both iron and vitamin B12 suggest the possibility of anemia, and the nurse should monitor the client for signs and symptoms of this condition, such as fatigue, pallor, and weakness.
Correct Answer is B
Explanation
A) "I do not need to sign a consent form before this procedure": This statement is incorrect. Most procedures involving intravenous (IV) dye or contrast require the client to sign a consent form. This is because the procedure involves the use of a contrast agent that could have potential risks or side effects, and the client needs to be informed and give consent for its use.
B) "I will feel a warming sensation after the injection of the dye": This statement is correct. It is common for patients to experience a warming or flushing sensation after the injection of IV contrast dye. This feeling is typically temporary and a normal response to the dye being introduced into the bloodstream. The nurse should reassure the client about this sensation.
C) "I should limit my fluid intake for 2 days after the procedure": This statement is incorrect. In most cases, clients are encouraged to increase their fluid intake after procedures involving IV contrast to help flush the dye from their system and prevent any potential kidney complications. Limiting fluid intake is generally not recommended unless otherwise instructed by the healthcare provider.
D) "I can have a meal up to 2 hours before the procedure": This statement is incorrect in many cases, especially if the procedure involves sedation or anesthesia. Typically, clients are instructed to fast for a period (usually 4–6 hours) before procedures involving contrast dye, particularly if anesthesia or sedation is used. Eating too soon before the procedure can increase the risk of aspiration or other complications. It’s important to follow specific instructions from the healthcare provider.
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