A nurse is caring for a client who is receiving a continuous infusion through a peripheral IV device. The nurse notes the catheter site is cool, swollen, blanched, and painful to touch. Which of the following actions should the nurse take?
Aspirate fluid from the IV cannula.
Place the affected extremity below the level of the client's heart.
Slow the IV infusion.
Place a pressure dressing over the IV site.
The Correct Answer is C
Choice A reason: Aspirating fluid from the IV cannula is not recommended as it does not address the issue of infiltration or extravasation.
Choice B reason: Placing the affected extremity below the level of the client's heart could worsen the swelling and is
not recommended.
Choice C reason: Slowing the IV infusion is a correct immediate action to minimize further infiltration and should be done while further assessment and interventions are planned.
Choice D reason: Placing a pressure dressing over the IV site is not recommended as it may exacerbate the infiltration
and increase discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sterile gloves are not required for inserting an NG tube; clean gloves are sufficient as the nasal
cavity is not a sterile environment.
Choice B reason: The client should not be asked to cough while inserting the NG tube as this could disrupt the placement process. Instead, the client may be asked to swallow to facilitate the passage of the tube.
Choice C reason: Placing the client into a left lateral position is not the standard position for NG tube insertion. The
client should be in an upright or semi-Fowler's position to aid in the insertion process.
Choice D reason: Determining the length of the NG tube to be inserted is a crucial step to ensure that the tube
reaches the stomach without coiling in the esophagus or extending into the small intestine.
Correct Answer is B
Explanation
Choice A reason: The left ventricle pumps oxygenated blood into the aorta and then to the rest of the body, not
directly to the lungs.
Choice B reason: The pulmonary artery is the correct answer because it carries deoxygenated blood from the right
ventricle of the heart to the lungs for oxygenation.
Choice C reason: The left atrium receives oxygenated blood from the lungs through the pulmonary veins, so it is not
involved in sending blood to the lungs.
Choice D reason: The pulmonary veins carry oxygenated blood from the lungs to the left atrium, not from the heart
to the lungs.
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