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 A
Explanation
Choice A reason: To calculate BMI, the nurse needs the client's height and weight. BMI is calculated by dividing the weight in kilograms by the square of height in meters.
Choice B reason: Skinfold thickness is used to estimate body fat percentage, not BMI.
Choice C reason: Waist circumference is used as a measure of abdominal obesity, not for calculating BMI.
Choice D reason: Daily calorie intake is not required for BMI calculation; it is more relevant for dietary assessments
and weight management plans.
Correct Answer is D
Explanation
Choice A reason: Cerebral edema is not typically a manifestation of hyperkalemia. Hyperkalemia can cause neurological symptoms due to its effect on nerve transmission, but cerebral edema is more commonly associated with conditions like traumatic brain injury, stroke, or brain tumors.
Choice B reason: Wheezing is a respiratory symptom and is not directly related to hyperkalemia. It is more commonly associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD).
Choice C reason: Hypoactive bowel sounds may indicate a gastrointestinal issue but are not a specific sign of hyperkalemia. Hyperkalemia can affect smooth muscle contraction and could potentially lead to intestinal motility issues, but this is not a primary manifestation.
Choice D reason: Decreased deep tendon reflexes can be a manifestation of hyperkalemia. Hyperkalemia affects the neuromuscular junction and can lead to muscle weakness, which may manifest as decreased reflexes. Normal potassium levels in the blood are typically between 3.5 and 5.0 millimoles per liter (mmol/L). Hyperkalemia occurs when potassium levels rise above 5.5 mmol/L.
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