The nurse is administering promethazine via an IV pump and notices that the IV has infiltrated and the patient reports a burning sensation at the injection site.
What should be the nurse’s priority action?
Notify the healthcare provider
Add promethazine to the allergy list
Continue to monitor the site
Stop the IV infusion .
The Correct Answer is D
Choice A rationale
While notifying the healthcare provider is an important step when an IV has infiltrated, it is not the immediate priority action.
Choice B rationale
Adding promethazine to the allergy list would not be appropriate unless the patient had an allergic reaction to the medication.
Choice C rationale
Continuing to monitor the site would not be the immediate priority action. The nurse should first stop the IV infusion to prevent further damage.
Choice D rationale
The nurse’s priority action should be to stop the IV infusion. This prevents further infiltration and potential tissue damage. After stopping the infusion, the nurse can then take further steps such as notifying the healthcare provider and assessing the patient’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While aromatherapy sprays can provide a calming environment, there is limited evidence to suggest that they can effectively reduce chemotherapy-induced nausea and vomiting.
Choice B rationale
Physical activity like a brisk walk outside can be beneficial for overall health, but it may not directly help in reducing nausea and vomiting caused by chemotherapy.
Choice C rationale
Avoiding well-seasoned, spicy, and fatty foods can help reduce nausea and vomiting during chemotherapy. These types of foods can irritate the stomach and make nausea worse.
Choice D rationale
Drinking a warm glass of milk may not be helpful in reducing chemotherapy-induced nausea and vomiting. In fact, dairy products can sometimes exacerbate nausea.
Correct Answer is B
Explanation
Choice A rationale
T3 and T4 are thyroid hormones. While it’s important to monitor these levels in a patient on propylthiouracil therapy, they are not the most concerning lab value.
Choice B rationale
The white blood cell count should be the nurse’s primary concern. Propylthiouracil can cause agranulocytosis, a serious condition characterized by a decrease in the number of white blood cells, which can lead to infection.
Choice C rationale
Hemoglobin and hematocrit levels are important to monitor, but they are not the most concerning lab value in this context.
Choice D rationale
While it’s important to monitor platelet count in a patient on propylthiouracil therapy, it’s not the most concerning lab value.
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