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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing a pillow under the patient’s knees can actually increase the risk of plantar flexion contractures by keeping the foot in a flexed position.
Choice B rationale
Positioning a trochanter roll under each of the patient’s hips would not directly prevent plantar flexion contractures. Trochanter rolls are typically used to maintain alignment and prevent external rotation of the hip.
Choice C rationale
Advising the patient to wear rubber-soled slippers would not directly prevent plantar flexion contractures. While rubber-soled slippers can provide safety benefits such as preventing slips and falls, they do not have a direct impact on the prevention of contractures.
Choice D rationale
Applying an ankle-foot orthotic device to the patient’s feet can help maintain the foot in a neutral position, thereby reducing the risk of developing plantar flexion contractures.
Correct Answer is C
Explanation
Choice A rationale
Assisting the patient to a left side-lying position with the right knee flexed is often used for rectal examinations or administering enemas, but it does not directly address the issue of a large amount of fecal material in the colon.
Choice B rationale
Preparing the patient for a chest x-ray would not be beneficial in this situation. A chest x-ray would not provide further information about the fecal material in the colon.
Choice C rationale
Administering a cleansing enema can help to remove the fecal material from the colon. This is a common treatment for fecal impaction.
Choice D rationale
Performing a manual digital examination of the patient’s rectum can help to assess the amount of fecal material present, but it would not alleviate the patient’s abdominal pain or remove the fecal material.
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