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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Denial is often the initial stage of the grieving process, characterized by disbelief or avoidance of the reality of the situation. Clients may refuse to accept the diagnosis or its implications, clinging to the hope that it is not true. The client's statement of "This cannot be happening to me" is consistent with denial, as they are expressing disbelief or resistance to the reality of their diagnosis.
A. This stage involves feelings of sadness, despair, and hopelessness. While depression is a common response to a terminal diagnosis, the client's statement of "This cannot be happening to me" suggests that they may still be in an earlier stage of grief.
B. Anger is another common stage of the grieving process, characterized by feelings of frustration, resentment, and hostility. Clients may direct their anger towards themselves, others, or even a higher power. While anger can be a prominent reaction to a terminal diagnosis, the client's statement does not explicitly express anger but rather disbelief or resistance.
C. Bargaining is a stage in which individuals may attempt to negotiate or make deals in an effort to change or postpone the inevitable outcome. For example, a client may pray for more time or promise to change their behavior in exchange for a better outcome. The client's statement of "This cannot be happening to me" does not reflect bargaining but rather denial or disbelief.

Correct Answer is A
Explanation
A. Confidentiality refers to the ethical duty of healthcare providers to safeguard patient information and maintain privacy. Upholding confidentiality means that healthcare providers must not disclose sensitive information about a patient to unauthorized individuals without the patient's consent. In this scenario, if the client asks the nurse not to disclose their medical diagnosis to their family members, respecting this request would uphold the principle of confidentiality by protecting the privacy of the patient's health information.
B. Justice in healthcare refers to the fair and equitable distribution of resources and the provision of healthcare services. While justice is an important ethical principle, it is not directly applicable to the client's request regarding the disclosure of their medical diagnosis to their family members.
C. Veracity, also known as truthfulness, is the ethical principle of honesty and truthfulness in communication with patients. Upholding veracity means providing patients with accurate and truthful information about their health condition and treatment options. In this scenario, if the nurse complies with the client's request not to disclose their medical diagnosis to their family members, it may involve withholding information and not fully disclosing the truth to the family members. Therefore, upholding the client's request may conflict with the principle of veracity.
D. A healthcare proxy is a legal document that allows an individual (the proxy) to make healthcare decisions on behalf of another person (the principal) if the principal is unable to make decisions for themselves. The existence of a healthcare proxy does not directly relate to the client's request regarding the disclosure of their medical diagnosis to their family members.
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