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 C
Explanation
Choice A reason: The reservoir bag on a nonrebreather mask should not collapse with exhalation. It is designed to maintain a continuous flow of oxygen and reserve a volume of oxygen for the patient to inhale with each breath.
Choice B reason: While high-flow oxygen can dry a patient's mucous membranes, a nonrebreather mask typically has a high oxygen flow rate, and humidification can be used to prevent drying.
Choice C reason: A nonrebreather mask must fit snugly over the patient's face to ensure that the highest concentration of oxygen is delivered and that there is minimal dilution with room air.
Choice D reason: A nonrebreather mask is used to deliver high-flow oxygen, not low-flow. It is designed to provide a high concentration of oxygen, typically around 60% to 90% FiO2.
Correct Answer is D
Explanation
Choice A reason: The small intestine is not the starting point of the digestive process. It is where most of the digestion and absorption of nutrients occurs after the food has been processed in the stomach.
Choice B reason: The rectum is the final section of the large intestine, where feces are stored before being expelled. It is not involved in the initial stages of digestion.
Choice C reason: The stomach is involved in the early stages of digestion, particularly in the breakdown of proteins, but it is not the starting point. Food enters the stomach after being ingested through the mouth.
Choice D reason: The mouth is the correct starting location for the digestive process. Here, ingestion takes place, and mechanical digestion begins with chewing, while chemical digestion starts with enzymes in the saliva breaking down carbohydrates.
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