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.

Answer and Explanation

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 C

Explanation

Answer is: c. Protect the IV bag from exposure to light.

Explanation: Nitroprusside degrades when exposed to light, so the nurse should protect the IV bag from light exposure to maintain the medication's potency and effectiveness in treating the client's severe hypertension.

Choice a. is wrong because calcium gluconate is used as an antidote for magnesium sulfate toxicity. Although it may be kept on hand in some facilities, it is not directly related to the administration of nitroprusside.

Choice b. is wrong because attaching an inline filter is not necessary when administering nitroprusside. It is more relevant for medications that require filtration, such as certain chemotherapeutic agents.

Choice d. is wrong because monitoring blood pressure every 2 hours is not frequent enough for a client receiving nitroprusside. The nurse should monitor the client's blood pressure more frequently, such as every 5 to 15 minutes, depending on facility policies and the client's condition.

A. Perform exercises prior to bedtime. B. Take a 1-hr nap during the day. C. Eat a light snack before bedtime. D. Stay in bed at least 1 hr if unable to fall asleep.

Correct Answer is C

Explanation

C) Eat a light snack before bedtime.

The nurse should include the instruction to eat a light snack before bedtime to promote nighttime sleep in an older adult. A light snack can help prevent hunger pangs during the night, making it easier to fall asleep and stay asleep.

The other options are not recommended for promoting nighttime sleep:

A) Performing exercises prior to bedtime can increase alertness and make it more difficult to fall asleep.

B) Taking a 1-hour nap during the day can disrupt the sleep-wake cycle and make it more challenging to sleep at night.

D) Staying in bed for at least 1 hour if unable to fall asleep is not recommended. If the client cannot fall asleep, it's better to get out of bed, engage in a quiet and relaxing activity, and return to bed when feeling sleepy to avoid frustration and anxiety associated with not being able to sleep.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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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?