Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

Apply heat to the infiltrated site.

Document a delay in the administration of the antibiotic.

Start a new IV at a different site to administer the antibiotic.

Remove the infiltrated IV catheter.

Answer and Explanation

The Correct Answer is D

A. Applying heat may be indicated later, but the first action should be to address the infiltration.

B. Documenting the delay is important but not the immediate priority.

C. Starting a new IV site is necessary for continued medication administration but should be done after addressing the infiltration.

D. Removing the infiltrated IV catheter is the first priority to prevent further tissue damage and start appropriate treatment for infiltration.

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Free Nursing Study Resources

Correct Answer is []

Explanation

In an infant, a bulging fontanel is a classic sign of increased intracranial pressure. The fontanel, or soft spot on the top of the skull, can bulge when there is a buildup of pressure inside the skull, often due to conditions like hydrocephalus or complications with a ventriculoperitoneal shunt.

Preparing for a CT scan is crucial for diagnosing underlying causes of increased intracranial pressure, which could be related to shunt issues or other intracranial abnormalities.

Implementing seizure precautions ensures safety and readiness for possible seizures due to elevated intracranial pressure.

Monitoring pupil size helps assess neurological status and detect signs of increased intracranial pressure.

Tracking heart rate helps in identifying changes that may indicate deterioration in the infant’s condition related to increased intracranial pressure.

A. Involve your mother in the decision-making process. B. Helping your mother should be easier than raising a child. C. You made a promise to your mother that you need to keep. D. Saying "no" to things involving the care of your mother is a selfish action. E. It is okay not to love or like your mother when you are caring for her.

Correct Answer is ["A","E"]

Explanation

A. Involve your mother in the decision-making process: Involving the client in decision-making can help maintain their sense of autonomy and dignity, and it can also alleviate some of the caregiver’s stress by sharing responsibilities and ensuring the client's preferences are considered.

B. Helping your mother should be easier than raising a child: Caregiving for an elderly parent can be just as challenging, if not more so, than raising a child. Comparing caregiving responsibilities to raising children may invalidate the caregiver’s feelings and experiences.

C. You made a promise to your mother that you need to keep: While promises can be important, emphasizing this can add additional pressure on the caregiver. Instead, focusing on practical support strategies and self-care might be more helpful.

D. Saying "no" to things involving the care of your mother is a selfish action: Caregivers need to set boundaries and prioritize their own well-being. Saying "no" when needed is essential to prevent burnout and maintain effective caregiving.

E. It is okay not to love or like your mother when you are caring for her: Acknowledging that it's normal to have complex emotions while caregiving can help the daughter understand that her feelings are valid and that seeking support or expressing her feelings is a healthy part of caregiving.

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Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Correct Answer is ["A","E"]

Explanation

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