A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.
Which of the following actions should the nurse plan to take?
Apply a pressure dressing at the IV site.
Place a warm, moist compress on the site.
Express drainage from the IV site and send it to be cultured.
Insert a new IV catheter distal to the discontinued IV site.
The Correct Answer is B
Choice A rationale:
Applying a pressure dressing at the IV site might be necessary after removing the catheter, but it does not address the inflammation and discomfort caused by phlebitis. Warm, moist compresses are more appropriate for this situation.
Choice B rationale:
Placing a warm, moist compress on the site is the correct action for phlebitis. Heat helps improve blood circulation, reduce inflammation, and provide relief from pain and discomfort. This choice addresses the client's condition effectively.
Choice C rationale:
Expressing drainage from the IV site and sending it for culture is not necessary in this context. Phlebitis is primarily an inflammatory condition, and drainage culture is not a standard practice for phlebitis.
Choice D rationale:
Inserting a new IV catheter distal to the discontinued IV site is not the immediate action to take for phlebitis. First, the nurse should address the inflammation and pain with warm compresses. If a new IV site is needed, it can be considered after managing the client's symptoms.
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Correct Answer is D
Explanation
Explanation: MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious infections in various parts of the body. The nurse should wear a gown when assisting the client with personal hygiene to prevent contact transmission of MRSA to other clients or staff members. The nurse should also wear gloves and a mask and perform hand hygiene before and after contact with the client or their environment. The nurse should remove personal protective equipment before leaving the client's room and dispose of it properly to avoid contamination of other areas or surfaces. Negative air pressure is not required for MRSA isolation because it is not an airborne infection. The client's visitors should not be restricted, but they should be educated on the proper use of personal protective equipment and hand hygiene when visiting the client.
Correct Answer is A
Explanation
Choice A rationale:
Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.
Choice B rationale:
Performing a fundal massage is incorrect choice in this scenario.
Choice C rationale:
Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.
Choice D rationale:
Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.
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