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 .

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Peripheral edema is not a common side effect of stopping steroids early. Peripheral edema is often associated with conditions such as heart failure, liver disease, or kidney disease.
Choice B rationale
Low blood pressure is a common side effect when a person stops taking steroids like prednisone abruptly. Prednisone is a glucocorticoid, a type of steroid that works to mimic the effects of cortisol, a hormone that the adrenal glands produce. The body uses cortisol to regulate the heart rate and blood pressure. When a person takes prednisone for longer than a few weeks, the body reduces the amount of cortisol it makes. When a person suddenly stops taking prednisone, the body cannot immediately produce enough cortisol to make up for the missing drug. This results in withdrawal symptoms, including low blood pressure.
Choice C rationale
Hyperglycemia, or high blood sugar, is not typically a withdrawal symptom of stopping steroids early. While long-term use of steroids can lead to increased blood sugar levels, stopping the medication does not typically cause hyperglycemia.
Choice D rationale
Weight loss can be a symptom of steroid withdrawal, but it is not the most immediate or common symptom that would be anticipated in a client who stopped taking their prescribed steroids early. More common symptoms include fatigue, joint pain, and low blood pressure.

A. Hyponatremia B. Hypermagnesemia C. Hypokalemia D. Hypercalcemia .

Correct Answer is B

Explanation

Choice A rationale
Hyponatremia, or low sodium levels, is not typically associated with the use of milk of magnesia. Milk of magnesia works by drawing water into the intestines, which can help to soften the stool and stimulate bowel movements. While it can affect fluid balance, it does not directly affect sodium levels in the body.
Choice B rationale
This choice is correct. Milk of magnesia contains magnesium and can lead to hypermagnesemia, or high magnesium levels, if taken in excess or if the client has impaired kidney function. Hypermagnesemia can cause various symptoms, including nausea, vomiting, low blood pressure, and in severe cases, heart arrhythmias and cardiac arrest.
Choice C rationale
Hypokalemia, or low potassium levels, is not typically associated with the use of milk of magnesia. While milk of magnesia can affect fluid and electrolyte balance, it does not directly affect potassium levels in the body.
Choice D rationale
Hypercalcemia, or high calcium levels, is not typically associated with the use of milk of magnesia. Milk of magnesia does not contain calcium, so it would not contribute to an increase in calcium levels in the body.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the clinic and reports that they stopped taking their prescribed steroids early because they felt much better. What side effect should the nurse anticipate in this client?

Correct Answer is B

Explanation

A client is prescribed milk of magnesia. After reviewing the client’s lab results, which potential electrolyte imbalance is the nurse concerned about?

Correct Answer is B

Explanation

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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?