The nurse is working on a neurosurgery unit. The patient calls the desk to complain that his arm is really burning and feels hot. The patient is receiving IV phenytoin for his grand mal seizures. What is the nurse's best action?
Call the health carer provider immediately to change the medication to oral.
Continue the infusion and reassure the patient.
Flush the line with 10 mL of normal saline and continue the infusion.
Discontinue the IV and restart the IV infusion in a different site
The Correct Answer is D
A. Call the health care provider immediately to change the medication to oral.
Changing the medication to oral may not address the immediate issue of the burning sensation and feeling of heat at the IV site. This option focuses on changing the route of administration rather than addressing the current discomfort.
B. Continue the infusion and reassure the patient.
Continuing the infusion without addressing the patient's discomfort could lead to potential complications, and it is important to prioritize patient comfort and safety. Reassurance alone may not be sufficient if there is an issue with the IV site.
C. Flush the line with 10 mL of normal saline and continue the infusion.
While flushing the line with normal saline is a good practice to ensure patency, it may not resolve the issue if there is ongoing irritation or infiltration at the site. Continuing the infusion without addressing the patient's complaint might lead to further discomfort.
D. Discontinue the IV and restart the IV infusion in a different site.
This is the best action. Discontinuing the IV allows the nurse to assess the current site for signs of infiltration or irritation. Restarting the IV in a different site addresses the immediate issue, ensuring that the medication is delivered safely and effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I need to increase my fluid intake." - This is a correct statement. Sucralfate should be taken with plenty of water to ensure proper absorption and effectiveness.
B. "I need to report pain or vomiting of blood." - This is also a correct statement. Severe abdominal pain or vomiting of blood may indicate a serious issue and should be reported to the healthcare provider.
C. "I need to take Carafate 30 minutes after meals." - This is an incorrect statement. Sucralfate is typically taken on an empty stomach, about 1 hour before meals and at bedtime.
D. "I need to take Maalox 30 minutes before or after Carafate." - This statement is correct. Antacids like Maalox can interfere with the absorption of sucralfate. It's generally recommended to space them apart, taking sucralfate at least 30 minutes before or after antacids.

Correct Answer is C
Explanation
A. Bethanechol (Urecholine)
Bethanechol is a cholinergic agonist used to treat urinary retention. It is not indicated for Alzheimer's disease.
B. Albuterol (Proventil)
Albuterol is a bronchodilator used to treat respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). It is not indicated for Alzheimer's disease.
C. Rivastigmine
Rivastigmine is a medication commonly used for the treatment of Alzheimer's disease. It belongs to a class of drugs called cholinesterase inhibitors, which work by increasing the levels of acetylcholine in the brain. This can help improve cognitive function in individuals with Alzheimer's disease.
D. Edrophonium (Enlon)
Edrophonium is a medication used for the diagnostic evaluation of Myasthenia Gravis. It is not used in the treatment of Alzheimer's disease.
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