A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.
On Day 1, Lactated Ringer’s was infusing at 100 mL/hr into a 20-gauge IV catheter in the left hand. The IV dressing was dry and intact.
The IV site was without redness or swelling. The IV fluid was infusing well.
On Day 2, the IV site was edematous.
The skin surrounding the catheter site was taut, blanched, and cool to touch. The IV fluid was not infusing.
The nurse is assessing the client.
Which of the following actions should the nurse take?

Stop the IV infusion.

Elevate the client’s left arm.

Apply heat to the client’s left hand.

Start a new IV in the client’s left hand.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

The nurse should stop the IV infusion. The client has manifestations of IV infiltration, which occurs when IV fluid enters the surrounding tissue. Stopping the IV infusion and removing the IV catheter can reduce the risk for further tissue damage.

Choice B rationale

The nurse should elevate the client’s left arm. Elevation can help decrease swelling and reduce the risk for tissue damage.

Choice C rationale

The nurse should apply heat to the client’s left hand. Heat can help reduce swelling and promote comfort.

Choice D rationale

Starting a new IV in the client’s left hand is not recommended at this point. The nurse should first manage the infiltration and then assess the need for a new IV3.

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Correct Answer is A

Explanation

Choice A rationale

After drawing up the medication, the nurse should ask another nurse to observe the medication wastage. This is a standard procedure for controlled substances like opioids. The second nurse acts as a witness to ensure that the unused portion of the medication is disposed of properly and not diverted for inappropriate use.

Choice B rationale

Notifying the pharmacy when wasting the medication is not the immediate next step after drawing up the medication. While some institutions may require notification of the pharmacy for controlled substance wastage, the immediate next step is typically to have another nurse witness the wastage.

Choice C rationale

Locking the remaining medication in the controlled substances cabinet is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

Choice D rationale

Disposing of the vial with the remaining medication in a sharps container is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

A. “We would give you oxygen through a tube in your nose.”. B. “You would be unable to change your previous wishes about your care.”. C. “We would insert a breathing tube while we evaluate your condition.”. D. “We would consult the person appointed by your health care proxy to make decisions.”. .

Correct Answer is A

Explanation

Choice A rationale

If a patient with a living will arrived at the emergency department with difficulty breathing, the healthcare team would provide immediate care to ease the patient’s distress, such as administering oxygen.

Choice B rationale

While a living will outlines a patient’s wishes for end-of-life care, it does not prevent the patient from receiving immediate, necessary care in an emergency situation.

Choice C rationale

Inserting a breathing tube may be necessary in some cases, but it would not be the first step in managing difficulty breathing.

Choice D rationale

While the healthcare team would consult the person appointed by the patient’s healthcare proxy to make decisions, immediate care would not be delayed.

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Naxlex Comprehensive Predictor Exams

A nurse is about to administer an injection of an opioid medication to a patient. The nurse has drawn 1 mL of the medication from a 2 mL vial.What should the nurse do next?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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