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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Positioning the primary IV solution bag higher than the piggyback medication bag creates a pressure gradient, allowing the primary solution to infuse first. Once the primary solution has finished, the secondary piggyback medication automatically starts infusing. This setup ensures that the primary solution is fully infused before the piggyback medication begins.
B. Placing the primary IV solution bag lower than the piggyback medication bag is not the standard practice. This setup would create a pressure gradient that could result in the piggyback medication infusing before the primary solution, which is not desirable. It could lead to incomplete infusion of the primary solution and compromise the effectiveness of the treatment.
C. Positioning the primary IV solution bag at the same height as the piggyback bag does not create a pressure gradient for sequential infusion. As a result, both solutions would flow at the same rate, and it would be challenging to control the order of infusion. This setup is not appropriate for administering IV antibiotics via piggyback because it does not ensure the proper sequence of infusion.
D. The height of the IV solution relative to the insertion site is essential for proper infusion and preventing complications such as infiltration or phlebitis. Ideally, the IV solution should be hung at a height that allows for a gentle flow of fluid into the vein without causing excessive pressure or backflow. Placing the IV solution lower than the insertion site helps facilitate gravity-assisted flow into the vein.
Correct Answer is D
Explanation
D. This statement indicates an understanding of hospice care. Pain management is a crucial component of hospice care, and ensuring that patients have access to effective pain medication and symptom management is a priority. Hospice aims to maximize comfort and quality of life for patients, and providing pain relief is a fundamental aspect of this approach.
A. This statement suggests that the client may not fully understand the purpose of hospice care. Hospice care is generally provided to patients with a terminal illness who have a life expectancy of six months or less. The focus of hospice care is on comfort, quality of life, and symptom management rather than curative treatment. Planning for travel and activities like fishing may not align with the goals of hospice care.
B. This statement indicates a misunderstanding of hospice care. In hospice, patients are typically encouraged to have their loved ones and family members present and involved in their care, especially during the end-of-life period. Hospice care emphasizes emotional support, spiritual care, and the importance of family involvement during the dying process.
C. This statement may or may not indicate an understanding of hospice care, as it depends on the specific hospice setting and individual preferences. While some hospice programs may provide care in a hospital setting, many hospice services are delivered in the patient's home or in a hospice facility. The key aspect of hospice care is to provide comfort and support in a setting that best meets the patient's needs and wishes.
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