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

Answer and Explanation

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.

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Correct Answer is C

Explanation

C. Respect for the deceased person's cultural and religious beliefs is crucial. Care should be provided in a manner that aligns with their customs and traditions. This may involve specific rituals, prayers, or practices depending on the individual's cultural or religious background.
A. While completing documentation on the death certificate is important for legal and administrative purposes, it is not the priority during post-mortem care.
B. While it's essential to handle the deceased person's belongings with care and ensure they are returned to the family, this task can typically wait until after the immediate post-mortem care has been provided. It's not the priority during the initial stages of post-mortem care.
D. This task is important, but it should be carried out after the completion of post-mortem care. Once the deceased person has been respectfully prepared, the next step is to transfer them to the morgue or the designated location.

A. "My family will need to shoulder the burden of my care." B. "I will be supported so I can be as independent as possible." C. "I should turn my care decisions over to my partner. D. "My neurologist will no longer care for me."

Correct Answer is B

Explanation

B. This statement demonstrates an understanding of palliative care as a supportive approach focused on optimizing independence and quality of life. Palliative care emphasizes symptom management, psychosocial support, and enhancing functional abilities to enable patients to live as fully and independently as possible, even in the context of a progressive neurologic disease. This statement aligns with the principles of palliative care, which aim to empower patients to make choices and maintain control over their lives.
A. This statement reflects a perception of palliative care as solely placing the responsibility of care on the family. While family support is an essential component of palliative care, it is not the sole responsibility of the family. Palliative care aims to provide comprehensive support to patients with serious illnesses, addressing physical, emotional, social, and spiritual needs. It involves a collaborative approach involving healthcare professionals, patients, and their families to ensure holistic care and quality of life.

C. This statement suggests a misconception about palliative care, equating it with relinquishing control of care decisions to a partner or caregiver. In reality, palliative care emphasizes patient-centered decision-making and supports patients in expressing their preferences, values, and goals of care. While caregivers play an important role in the palliative care team, ultimate decision-making authority rests with the patient, and care plans are tailored to align with the patient's wishes and priorities.
D. This statement reflects a misunderstanding of palliative care as a replacement for disease-specific medical care, such as neurology. Palliative care is not mutually exclusive with disease-focused treatment but rather complements it by addressing the broader physical, emotional, and social needs of patients with serious illnesses, including progressive neurologic diseases. Palliative care can be provided concurrently with disease-specific treatments and involves a multidisciplinary team, which may include specialists like neurologists, to ensure comprehensive care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

Correct Answer is C

Explanation

The nurse is caring for a client who has been diagnosed with an exacerbation of a progressive neurologic disease. The nurse recognizes that the client understands palliative care when the client states:

Correct Answer is B

Explanation

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