A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.
(Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).
Remove the IV catheter.
Apply warm or cold compresses.
Stop the infusion.
Apply a sterile dressing.
Elevate the extremity.
The Correct Answer is C,A,D,E,B
Here’s the correct order of actions a nurse should take when infiltration is identified at an IV site: C. Stop the infusion A. Remove the IV catheter D. Apply a sterile dressing E. Elevate the extremity B. Apply warm or cold compresses ? Rationale: Stopping the infusion prevents further infiltration. Removing the catheter eliminates the source of fluid leakage. Applying a sterile dressing protects the site from infection. Elevation helps reduce swelling. Compresses (warm for older infiltrations, cold for recent ones) promote absorption and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Turning the client’s head to the side is important to prevent aspiration, but it should be done after documenting the time the seizure began.
Choice B rationale:
The first action when a client begins having a tonic-clonic seizure is to document the time the seizure began. This helps in determining the duration of the seizure, which is critical information for the healthcare team.
Choice C rationale:
Loosening the clothing around the client’s waist is important for the client’s comfort and safety during a seizure, but it should be done after documenting the time the seizure began.
Choice D rationale:
Checking the client’s motor strength is not the first action to take when a client begins having a tonic-clonic seizure.
Correct Answer is D
Explanation
Choice A rationale:
Apneustic respirations are characterized by prolonged inspiratory phase with shortened expiratory phase, not alternating periods of hyperventilation and apnea.
Choice B rationale:
Stridor is a high-pitched, wheezing sound caused by disrupted airflow, not a pattern of breathing.
Choice C rationale:
Kussmaul respirations are deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis, not alternating periods of hyperventilation and apnea.
Choice D rationale:
Cheyne-Stokes respirations are characterized by alternating periods of hyperventilation and apnea.
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