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 B
Explanation
Choice A rationale
While colonoscopy is a screening method for colon cancer, it is not typically recommended to begin at age 60 for individuals at average risk. Instead, colonoscopy screening is usually recommended to begin at age 50 and continue every 10 years if no polyps are found.
Choice B rationale
The recommendation for an average risk individual for colon cancer is to have a fecal occult blood test every year. This test checks for hidden blood in the stool, which can be an early sign of cancer.
Choice C rationale
Sigmoidoscopy every 10 years is another screening option for colon cancer. However, it only examines the rectum and lower third of the colon, whereas a colonoscopy examines the entire colon.
Choice D rationale
Blood tests are not typically used as a primary screening method for colon cancer. They may be used in conjunction with other tests, but a blood sample alone is not sufficient for screening.
Correct Answer is A
Explanation
Choice A rationale
The statement “What did I do to deserve this illness?” could indicate spiritual distress. This statement suggests that the patient may be struggling with feelings of guilt, punishment, or existential crisis, which are common manifestations of spiritual distress. The patient may be
questioning their moral or spiritual worth, or trying to find meaning or purpose in their suffering.
Choice B rationale
The statement “I blame medical science for not finding a cure” could indicate frustration or anger, but it does not necessarily indicate spiritual distress. While this statement suggests dissatisfaction with medical progress, it does not directly relate to the patient’s spiritual or existential concerns.
Choice C rationale
The statement “Where is my daughter when I need her most?” could indicate emotional distress related to the patient’s interpersonal relationships, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel abandoned or unsupported, but it does not directly relate to the patient’s spiritual or existential concerns.
Choice D rationale
The statement “Will I ever regain control over my life?” could indicate emotional distress related to the patient’s sense of autonomy and control, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel helpless or powerless in the face of their illness, but it does not directly relate to the patient’s spiritual or existential concerns.
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