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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: Initiate continuous cardiac monitoring.
Choice A rationale:
Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by severe dehydration due to osmotic diuresis, and fluid replacement is a critical component of treatment to restore hydration and circulatory volume.
Choice B rationale:
Monitoring vital signs every 8 hours is not sufficient for a child with DKA. DKA is an acute, life-threatening condition that requires close monitoring of vital signs to detect changes in the patient’s condition promptly. Vital signs should be monitored more frequently, typically every 1 to 2 hours, depending on the severity of the DKA and institutional protocols.
Choice C rationale:
Continuous cardiac monitoring is recommended for a child with DKA. DKA can lead to serious electrolyte imbalances, such as hypokalemia, which can cause cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these potential complications.
Choice D rationale:
Administering subcutaneous insulin 30 minutes before meals is not appropriate for the acute management of DKA. In DKA, insulin is typically administered intravenously to rapidly decrease blood glucose levels and correct metabolic acidosis. Subcutaneous insulin is not used until the patient is stable and able to eat.
Correct Answer is B
Explanation
Choice A rationale:
Taking ibuprofen during pregnancy is generally not recommended, especially in high doses or for an extended period, as it can increase the risk of complications, including heart defects in the baby. Therefore, advising the client to take 600 milligrams of ibuprofen every 8 hours is not appropriate and potentially harmful during pregnancy.
Choice B rationale:
Having a cesarean birth (C-section) is recommended if there are visible lesions of genital herpes during labor and delivery. This precautionary measure helps prevent the transmission of the herpes simplex virus (HSV) from the mother to the baby, reducing the risk of neonatal herpes infection, which can be severe or even life-threatening.
Choice C rationale:
Testing the baby's cord blood for HSV is not a standard practice. Instead, if there are visible lesions or symptoms of herpes during labor, a C-section is often performed to minimize the risk of transmission. Testing the baby after birth may be done if there are concerns about potential exposure.
Choice D rationale:
Applying a cortisone cream to the lesions is not recommended without medical supervision during pregnancy. Topical corticosteroids, such as cortisone creams, can be absorbed through the skin and may have adverse effects on both the mother and the baby. It is essential to consult a healthcare provider before using any medications or creams during pregnancy to ensure safety for both the mother and the baby.
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