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 ["3"]
Explanation
To calculate the dosage of furosemide (Lasix), a diuretic medication, you need to divide the ordered amount by the tablet strength.
In this case, the ordered amount is 120 mg and the tablet strength is 40 mg.
Therefore, you need to divide 120 by 40, which gives you 3.
This means you would administer 3 tablets of furosemide (Lasix) to the patient.
Correct Answer is ["75"]
Explanation
To calculate the rate of IV infusion, the nurse should divide the volume of fluid by the time in hours.
In this case, 750 mL divided by 10 hours equals 75 mL per hour.
Therefore, the nurse should program the IV infusion pump for 75 mL per hour.
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