Select the 2 actions the nurse should prepare to take for the client.

Administer phytonadione (Vitamin K): Contraindicated

There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition.

Apply cool compress to the extremity: Anticipated

A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues.

Elevate extremity: Anticipated

Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery.

Suggest irrigating the IV catheter: Contraindicated

Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately.

Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated

A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration.

Send the catheter tip for culture: Anticipated

Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.

A) Withhold the medication if pulse rate is less than 60/min: Enalapril, an ACE inhibitor, primarily affects blood pressure and does not typically require withholding based on pulse rate alone. Withholding enalapril is not recommended unless instructed by the healthcare provider for other reasons, such as a significant drop in blood pressure. The issue at hand is likely related to orthostatic hypotension rather than pulse rate.

B) Increase dietary potassium: Enalapril can increase potassium levels in the blood due to its effect on the renin-angiotensin system, potentially leading to hyperkalemia. Clients should avoid excessive potassium intake, especially through supplements or potassium-rich foods, unless advised by their healthcare provider. Increasing potassium may exacerbate any existing risks.

C) Decrease daily fluid intake: Decreasing fluid intake is not a recommended intervention for managing syncope related to enalapril. In fact, reducing fluid intake can exacerbate dehydration or low blood pressure, potentially worsening symptoms. Adequate hydration is typically important for managing blood pressure and syncope risk.

D) Rise slowly from a sitting position to a standing position: This is the most appropriate
advice. Enalapril can cause orthostatic hypotension, a condition in which blood pressure drops when changing positions (such as from sitting to standing). This can lead to dizziness or syncope. Rising slowly from a sitting position helps prevent a sudden drop in blood pressure and reduces the risk of fainting. Clients should be instructed to take this precaution until the body adjusts to the medication’s effects.