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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:
Basal cell carcinoma often appears as a raised, flesh-colored lesion with pearly, white borders. It is the most common type of skin cancer.
Choice B rationale:
Actinic keratosis is a precancerous skin condition that can lead to squamous cell carcinoma if left untreated. It typically presents as dry, scaly patches or spots.
Choice C rationale:
Squamous cell carcinoma often appears as a firm, red nodule or a flat lesion with a scaly, crusted surface.
Choice D rationale:
Malignant melanoma is a more serious type of skin cancer that can develop anywhere on the body. It often appears as a new, irregular, or changing mole.

A. Change the IV site dressing every 4 days. B. Obtain the client's blood glucose every 12 hr. C. Weigh the client every other day. D. Change the IV tubing every 24 hr.

Correct Answer is D

Explanation

Choice A rationale:
The IV site dressing should be changed every 7 days, not every 4 days.
Choice B rationale:
The client’s blood glucose should be monitored every 4-6 hours, not every 12 hours.
Choice C rationale:
The client should be weighed daily, not every other day.
Choice D rationale:
The IV tubing for TPN should be changed every 24 hours to prevent infection.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly, white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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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.).