A nurse is monitoring a client’s peripheral IV infusion of a vesicant medication and observes swelling and coolness of the skin at the insertion site. After stopping the infusion, which of the following actions should the nurse take next?

Notify the provider.

Apply a warm, moist compress.

Aspirate fluid remaining in the catheter.

Remove the IV catheter.

Answer and Explanation

The Correct Answer is D

A. Notify the provider. While notifying the provider is important, it is not the immediate next step after stopping the infusion. The priority is to prevent further damage by removing the IV catheter.
B. Apply a warm, moist compress. This action may be appropriate depending on the type of vesicant, but it is not the immediate next step. The priority is to remove the IV catheter to prevent further extravasation.
C. Aspirate fluid remaining in the catheter. This action can help to remove any remaining vesicant from the tissue, but it is not the immediate next step. The priority is to remove the IV catheter.
D. Remove the IV catheter. This is the correct next step after stopping the infusion. Removing the catheter helps to prevent further leakage of the vesicant into the surrounding tissue, minimizing the risk of tissue damage.

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Correct Answer is C

Explanation

A. Diarrhea is not a common adverse effect of total parenteral nutrition (TPN). TPN is administered intravenously, bypassing the gastrointestinal tract, so it does not typically cause diarrhea.
B. Aspiration pneumonia is not associated with TPN, as TPN is delivered directly into the bloodstream and does not involve the respiratory system.
C. Electrolyte imbalance is a significant adverse effect of TPN. TPN solutions contain various electrolytes, and improper formulation or administration can lead to imbalances, which can cause serious complications such as cardiac arrhythmias, muscle weakness, and neurological issues.
D. Nausea is not commonly associated with TPN, as it bypasses the gastrointestinal tract. Nausea may occur due to other underlying conditions but is not a direct adverse effect of TPN.

Correct Answer is ["50"]

Explanation

Step 1: Determine the total volume to be infused. 100 mL

Step 2: Determine the time in minutes over which the infusion will be administered. 30 minutes

Step 3: Calculate the flow rate in mL/min. 100 mL ÷ 30 minutes = 3.33 mL/min

Step 4: Calculate the flow rate in gtt/min using the drop factor. 3.33 mL/min × 15 gtt/mL = 49.95 gtt/min

Step 5: Round to the nearest whole number. 50 gtt/min

The nurse should set the manual IV infusion to deliver 50 gtt/min.

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A nurse is monitoring a client’s peripheral IV infusion of a vesicant medication and observes swelling and coolness of the skin at the insertion site. After stopping the infusion, which of the following actions should the nurse take next?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving total parenteral nutrition. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is C

Explanation

Correct Answer is ["50"]

Explanation

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