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 ["A","B","C","D"]
Explanation
Choice A rationale
Regular inspection of the cord for frays or tears is crucial to ensure the safe operation of the home oxygen concentrator. A damaged cord can pose a risk of electric shock or fire.
Choice B rationale
Keeping the unit at least 1.2 m (4 ft) away from a gas stove is important because oxygen supports combustion. An oxygen-rich environment can cause materials to ignite more easily and make fires burn at a faster rate.
Choice C rationale
Considering the purchase of a generator for power backup is a good idea. In case of a power outage, a backup power source would ensure the continuous operation of the oxygen concentrator, which is critical for patients who are dependent on supplemental oxygen.
Choice D rationale
Monitoring for signs of hypoxia is essential. Despite receiving oxygen therapy, a patient may still experience hypoxia if the oxygen flow rate is insufficient, or if there are issues with the equipment. Signs of hypoxia include shortness of breath, rapid breathing, restlessness, confusion, and cyanosis (bluish color of the skin, lips, or nails)12.
Choice E rationale
Choosing synthetic clothing and bedding is not recommended. Synthetic materials can build up static electricity, which can spark and cause a fire in an oxygen-enriched environment.
Correct Answer is B
Explanation
Choice A rationale
The client was admitted three days ago. This statement is factual, but it does not directly address the current condition of the client’s pressure injury. The time of admission is not as relevant as the progression and treatment of the wound. Therefore, while this choice is accurate, it is not the most critical piece of information in this context.
Choice B rationale
The pressure injury was at stage 4. This is the correct answer. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage or bone.
The presence of slough, eschar, and tunnels, as well as the size of the wound, are consistent with a stage 4 pressure ulcer. The treatment provided, including debridement and negative
pressure wound therapy, is also typical for this stage of pressure injury. Therefore, this choice accurately describes the client’s condition.
Choice C rationale
The client reported pain as a 2 on a scale from 0 to 10. While it’s important to monitor the client’s pain levels, this information alone does not provide a comprehensive understanding of the client’s condition. Pain can be subjective and varies from person to person. A score of 2 indicates minor pain, which is manageable and does not significantly interfere with the client’s daily activities. However, this does not negate the severity of a stage 4 pressure injury.
Choice D rationale
The dressing was reapplied and sealed. This statement describes one aspect of the wound care process. Negative pressure wound therapy involves the application of a vacuum through a special sealed dressing. The dressing is crucial in creating a moist healing environment, reducing edema, and promoting wound healing. However, the reapplication and sealing of the dressing alone do not provide a complete picture of the client’s condition or the severity of the pressure injury.
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