The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?

Stop the infusion immediately

Document the findings in a nurse's note

Flush the catheter with 3ml normal saline

Remove the catheter and apply pressure to the site

Answer and Explanation

The Correct Answer is A

A. Infiltration occurs when the intravenous solution leaks into the surrounding tissue instead of flowing into the vein. This can cause discomfort, swelling, and potential tissue damage. Stopping the infusion immediately helps prevent further infiltration and minimizes the risk of complications such as tissue necrosis or damage.
B. While documenting the findings is important for the client's medical record, it is not the first action to take when suspecting infiltration. Immediate intervention to stop the infusion and assess the site for complications takes precedence over documentation.
C. Flushing the catheter with normal saline may be necessary after stopping the infusion to ensure patency and clear any remaining solution from the catheter. However, this step should follow the immediate cessation of the infusion to prevent further infiltration.
D. Removing the catheter may be necessary if significant infiltration has occurred or if there are signs of tissue damage. However, this should be done after stopping the infusion to prevent further infiltration and should be based on the assessment findings and healthcare provider's instructions.

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Correct Answer is A

Explanation

A. In respiratory alkalosis, the pH is elevated (alkalotic), the PaCO2 (partial pressure of carbon dioxide) is decreased (hypocapnia), and the HCO3 (bicarbonate) level may be within normal limits or slightly decreased due to compensatory mechanisms. In this option, the pH is elevated (7.54), the PaCO2 is decreased (25), and the HCO3 level is within normal limits (24). These findings support respiratory alkalosis.
B. pH 7.50, PaCO2 40, HCO3 28: In this option, the pH is elevated (7.50), the PaCO2 is within normal limits (40), and the HCO3 level is elevated (28). These findings are not consistent with respiratory alkalosis. Instead, they suggest metabolic alkalosis, where both the pH and bicarbonate levels are elevated.
C. pH 7.35, PaCO2 35, HCO3 22: In this option, the pH is within normal limits (7.35), the PaCO2 is within normal limits (35), and the HCO3 level is within normal limits (22). These findings are not consistent with respiratory alkalosis.
D. pH 7.32. PaCO2 48, HCO3 24: In respiratory alkalosis, the pH is elevated (alkalotic), the PaCO2 is decreased (hypocapnia), and the HCO3 level may be within normal limits or slightly decreased due to compensatory mechanisms. In this option, the pH is within normal limits (7.32), the PaCO2 is elevated (48), and the HCO3 level is within normal limits (24). These findings are not consistent with respiratory alkalosis.

A. pH 7.29 B. Pa CO2 54 C. pH 7.51 D. PaO2 72 E. Pa CO2 31

Correct Answer is ["A","B"]

Explanation

A. pH 7.29: A respiratory rate of 6 breaths per minute suggests hypoventilation, which can lead to respiratory acidosis due to retention of carbon dioxide (CO2). A decrease in pH (acidosis) is expected in this scenario.
B. PaCO2 54: In respiratory acidosis, PaCO2 levels are elevated due to inadequate ventilation, leading to CO2 retention. Therefore, an elevated PaCO2 level would be anticipated in this situation.
C. pH 7.51: A pH of 7.51 indicates alkalosis, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
D. PaO2 72: Oxygenation may be impaired in opioid overdose due to respiratory depression, but this PaO2 level is within the normal range. Hypoxemia is not typically a prominent feature of respiratory acidosis unless there are concurrent respiratory conditions or complications. Therefore, this choice is not anticipated.
E. PaCO2 31: A PaCO2 level of 31 indicates hypocapnia, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.

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