Which solution could cause blistering and ulceration at an IV site?
Hypotonic solution
Vitamin infusion
Vesicant
Isotonic fluid
The Correct Answer is C
A. Hypotonic solution: Hypotonic fluids cause water to move into cells, which may lead to cellular swelling or hemolysis if infused improperly. They do not directly cause tissue necrosis, blistering, or ulceration at the IV site. Local tissue injury of this severity is not typical.
B. Vitamin infusion: Most vitamin infusions are considered non-vesicant and are diluted to reduce irritation. While mild local irritation may occur, they do not produce the severe tissue damage associated with blistering or ulceration. Tissue necrosis is not an expected effect.
C. Vesicant: Vesicant medications cause severe tissue injury if they leak into surrounding tissue. Extravasation can result in blistering, ulceration, necrosis, and long-term tissue damage due to direct cytotoxic effects. Immediate intervention is required when vesicant extravasation is suspected.
D. Isotonic fluid: Isotonic fluids have a similar osmolarity to plasma and are generally well tolerated by peripheral veins. They do not disrupt cellular integrity or cause local tissue destruction. Blistering and ulceration are not associated with isotonic IV solutions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Clarify with the prescribing provider whether the order is to be given routinely or as needed (PRN), and determine the frequency of administration before giving the medication: The prescription does not specify whether it is PRN or scheduled, nor the minimum interval between doses. Clarification ensures safe, legal, and appropriate administration.
B. Administer 2 tablets of aspirin immediately, as the dose is clearly stated and the patient reports pain: Administering the medication without clarification could result in inappropriate dosing or exceed safe daily limits. Dose amount alone does not confirm safe timing or frequency.
C. Hold the medication and wait for the patient to request it again to confirm continued pain before administering: While assessing pain is important, withholding medication without clarification from the provider could delay pain relief and does not address the ambiguity in the order.
D. Give one tablet now and the second tablet after 30 minutes if pain persists, following standard pain management protocols: Altering the prescribed dose without provider instruction is unsafe and constitutes medication error. Standard protocols cannot override unclear prescriptions without clarification.
Correct Answer is D
Explanation
Calculation:
- Identify the ordered dose and tablet strength
Ordered Dose: 150 mg
Tablet Strength: 75 mg per tablet
- Calculate the number of tablets to administer
Number of Tablets = Ordered Dose ÷ Tablet Strength
Number of Tablets = 150 ÷ 75
= 2
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