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 C

Explanation

Choice A rationale:
Cleaning the perineal area with antiseptic solution daily is not necessary and can disrupt normal flora.
Choice B rationale:
Routine irrigation of the catheter is not recommended as it can introduce bacteria.
Choice C rationale:
Checking the catheter tubing for kinks or twisting ensures urine flow and prevents infection.
Choice D rationale:
Replacing the catheter every 3 days is not necessary and can increase infection risk.

A. Thrombotic stroke. B. Transient ischemic attack (TIA). C. Hemorrhagic stroke. D. Embolic stroke.

Correct Answer is C

Explanation

Choice A rationale:
A thrombotic stroke occurs when a blood clot forms in one of the arteries that supply blood to the brain. It does not typically cause a sudden, severe headache and vomiting.
Choice B rationale:
A transient ischemic attack (TIA), or “mini-stroke,” is a temporary blockage of blood flow to the brain. It does not cause a sudden, severe headache and vomiting.
Choice C rationale:
A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the brain. This can cause a sudden, severe headache and vomiting.
Choice D rationale:
An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of stroke does not typically cause a sudden, severe headache and vomiting.

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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.).

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Correct Answer is C

Explanation

Correct Answer is C

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.).