A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Remove the dressing and tape from the venipuncture site.

Clamp the IV tubing.

Withdraw the catheter from the client's vein.

Perform hand hygiene.

Apply pressure to the venipuncture site with sterile gauze.

Answer and Explanation

Correct Answer : A,B,C,D

A. Remove the dressing and tape from the venipuncture site: The dressing and tape are removed after the IV tubing is clamped to prevent fluid leakage. This step exposes the catheter for safe removal while maintaining sterility.

B. Clamp the IV tubing: Clamping the tubing stops the flow of IV fluids and prevents backflow or bleeding from the catheter. This ensures safety before manipulating the catheter.

C. Withdraw the catheter from the client's vein: The catheter is gently removed after the site is exposed and the tubing is clamped. Smooth withdrawal minimizes trauma and reduces the risk of bleeding or venous injury.

D. Perform hand hygiene: Hand hygiene should be done before any procedure to reduce the risk of introducing infection. It ensures aseptic technique is maintained throughout the IV discontinuation process.

E. Apply pressure to the venipuncture site with sterile gauze: Immediate pressure is applied after catheter removal to prevent bleeding and promote clot formation. The site is held until hemostasis is achieved and then dressed appropriately.

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Correct Answer is A

Explanation

A. Diarrhea: Cephalexin, like other antibiotics, can disrupt normal gut flora and lead to antibiotic-associated diarrhea. Severe or persistent diarrhea may indicate a more serious condition, such as Clostridioides difficile infection, which requires prompt medical evaluation. Monitoring and reporting this symptom is important for preventing complications.

B. Insomnia: Insomnia is not a common adverse effect of cephalexin. While some medications can cause sleep disturbances, cephalexin’s side-effect profile primarily involves gastrointestinal and hypersensitivity reactions rather than central nervous system effects.

C. Vertigo: Vertigo is not typically associated with cephalexin therapy. Neurological symptoms are rare and usually linked to other drug classes or preexisting conditions. Persistent dizziness would require evaluation, but it is not expected with standard cephalexin use.

D. Hypotension: Cephalexin does not normally cause hypotension. Blood pressure changes are uncommon unless a severe allergic reaction occurs, which would present with multiple systemic symptoms, such as rash, swelling, or difficulty breathing.

A. Avocado B. Bananas C. Tomato soup D. Black beans

Correct Answer is D

Explanation

A. Avocado: Avocados contain healthy fats and some protein, but the protein content is relatively low compared with legumes and other plant-based protein sources. They are more valuable for providing calories and essential fatty acids than protein.

B. Bananas: Bananas are primarily a source of carbohydrates and contain minimal protein. They are useful for energy and potassium but do not significantly contribute to protein intake in a vegetarian diet.

C. Tomato soup: Tomato soup is mostly water and carbohydrates with very little protein unless it is fortified or contains added legumes or dairy. It is not a reliable source of protein for postoperative nutrition.

D. Black beans: Black beans are rich in plant-based protein, fiber, and essential nutrients. They provide a substantial amount of protein per serving, making them an excellent choice for a vegetarian client needing increased protein intake during postoperative recovery.

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A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

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A nurse is reinforcing teaching with a client who has a new prescription for cephalexin to treat a urinary tract infection. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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