A patient receiving IV potassium complains of burning along the vein. What action should the nurse take first?
Slow down the rate of infusion.
Apply a warm compress to the site.
Discontinue the infusion.
Switch the IV site immediately.
The Correct Answer is A
A. Slow down the rate of infusion: Potassium chloride is a known chemical irritant to the endothelial lining of small peripheral veins. Reducing the infusion rate decreases the concentration of the solute passing through the vessel per unit of time, which often alleviates the burning sensation. This is the first conservative action to maintain the IV line.
B. Apply a warm compress to the site: A warm compress can promote vasodilation and potentially soothe the area, but it does not address the cause of the irritation. While it is a helpful supportive measure, the nurse should first modify the administration parameters of the irritant. It is a secondary intervention following the rate adjustment.
C. Discontinue the infusion: Stopping the infusion is an aggressive step that may be necessary if there are signs of infiltration or phlebitis, such as swelling or redness. However, burning alone is a common side effect of potassium and can often be managed without losing the IV access. The nurse should try rate modification before total discontinuation.
D. Switch the IV site immediately: Changing the IV site is premature if the current site is patent and showing no objective signs of extravasation or tissue damage. Repeatedly starting new IVs can deplete the patient's venous access options unnecessarily. The nurse should attempt to manage the irritation at the current site first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoid combining with antihistamines: Many allergy regimens safely combine decongestants for acute relief with antihistamines for long-term symptom control. There is no contraindication to using these two classes together to address different pathways of the allergic response. They provide additive benefits for the patient.
B. Take every 4 hours regardless of symptoms: Decongestants should be used sparingly and only when symptomatic to minimize systemic absorption and local irritation. Frequent, scheduled dosing increases the risk of side effects like tachycardia and hypertension. Using them on an "as-needed" basis is the safer clinical approach.
C. Discontinue as soon as symptoms resolve: While this is true for most symptomatic treatments, the specific instruction for decongestants must focus on the maximum duration of use. Even if symptoms persist, the patient must stop after 5 days to avoid rebound effects. The duration of therapy is more critical than the resolution of symptoms.
D. Use for no more than 3 to 5 days: Intranasal sympathomimetics provide rapid relief by constricting nasal blood vessels, but prolonged use leads to down-regulation of alpha-adrenergic receptors. This results in severe rebound vasodilation and mucosal edema when the drug is stopped. Limiting use prevents the development of rhinitis medicamentosa.
Correct Answer is D
Explanation
A. Advise combining antihistamines with decongestants for enhanced efficacy:While these are often paired, the combination can increase the risk of side effects like tachycardia or insomnia. The nurse should not advise on combinations without a specific provider order. This does not address the most critical safety concern regarding antihistamine use.
B. Monitor blood pressure regularly to prevent rebound hypertension:Rebound hypertension is more commonly associated with the overuse of topical nasal decongestants, not systemic antihistamines. While monitoring vitals is good practice, it is not the primary safety priority for this drug class. Antihistamines are more likely to cause sedation than significant hypertensive crises.
C. Limit the client's fluid intake to reduce mucus production:Restricting fluids is contraindicated as it can lead to thickening of secretions, making them harder to expectorate. Adequate hydration is actually encouraged to help thin mucus during a respiratory infection. This advice would be scientifically unsound and potentially harmful to the patient.
D. Educate about potential drowsiness and caution against driving:First-generation antihistamines readily cross the blood-brain barrier and antagonize H1 receptors in the central nervous system. This causes significant impairment of motor skills and cognitive function, creating a major safety risk. Patient education on injury prevention is the most critical nursing intervention.
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