The nurse is caring for a client receiving an intravenous medication that is a vesicant. The IV flow has stopped and there is pain, burning and swelling at the IV site. What action should the nurse take first?
Elevate the extremity on a pillow
Immediately remove the catheter
Keep the catheter in place
Place a cool compress on the area
The Correct Answer is B
B. When a client experiences symptoms of extravasation, such as pain, burning, and swelling, especially with a vesicant medication, the priority is to stop the infusion and remove the catheter immediately to prevent further tissue damage. Removing the catheter promptly helps minimize the amount of medication that may have leaked into the surrounding tissues.
A. Elevating the extremity on a pillow may help reduce swelling and discomfort in some cases, but it is not the first action the nurse should take when a vesicant medication has caused pain, burning, and swelling at the IV site.
C. Keeping the catheter in place is not advisable when extravasation has occurred, especially with a vesicant medication. Continuing the infusion could lead to further tissue damage and exacerbate the client's symptoms. Removing the catheter is necessary to prevent additional medication from entering the surrounding tissues.
D. While applying a cool compress may provide temporary relief from discomfort, it is not the first action the nurse should take when managing extravasation caused by a vesicant medication. The priority is to stop the infusion, remove the catheter, and assess the extent of tissue damage. Cool compresses may be used after the catheter removal to help reduce swelling and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Negligence refers to the failure to exercise reasonable care that results in harm to another person. It occurs when a healthcare provider fails to perform their duties according to the standard of care expected in their profession, leading to injury or harm to the patient. In the scenario described, the failure to follow orders for turning and positioning, resulting in pressure injuries, is an example of negligence. Negligence can result from actions (acts of commission) or omissions (acts of omission).
A. Battery refers to the intentional harmful or offensive touching of another person without their consent. In healthcare, battery may occur if a medical procedure is performed on a patient without their informed consent or if a procedure goes beyond the scope of what was consented to. In the context of the scenario provided, the development of pressure injuries due to inadequate turning and positioning is not an example of battery because it does not involve intentional harm.
C. Assault refers to the intentional threat of harm or the creation of fear of imminent harm in another person. In healthcare, assault may occur if a healthcare provider threatens a patient with harm or performs a procedure without their consent, creating fear or apprehension in the patient. In the context of the scenario provided, the development of pressure injuries due to inadequate turning and positioning is not an example of assault because it does not involve intentional threats or actions creating fear in the patient.
D. A felony is a serious criminal offense punishable by imprisonment or death. It typically involves actions that are considered extremely harmful or dangerous to society. The scenario described does not involve actions that rise to the level of a felony offense.
Correct Answer is B
Explanation
B. This client's excitement to learn about a new prosthesis indicates a positive attitude towards rehabilitation and a willingness to engage in the learning process. Their enthusiasm suggests a high level of motivation to adapt to their new prosthesis and incorporate it into their daily life. Therefore, this client exhibits a high motivation to learn.
A. This client's struggle with following nursing directives regarding discharge goals suggests a lack of motivation or difficulty engaging in the rehabilitation process. They may be experiencing challenges or barriers that are impeding their progress. Therefore, they do not exhibit the highest motivation to learn at this time.
C. While this client may have valuable experience and insights to share with newcomers, being a "coach" does not necessarily indicate a high motivation to learn for themselves. While they may be motivated to help others, it doesn't necessarily reflect their own eagerness to engage in learning activities for their own rehabilitation goals.
D. This client's eagerness to be discharged may suggest a desire to move on from the rehabilitation facility rather than a motivation to engage in learning activities related to their rehabilitation. They may be more focused on the end goal of leaving the facility rather than actively participating in the rehabilitation process.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
