Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client is receiving an intravenous (IV) infusion of potassium chloride. The nurse notices that the infusion site is red, swollen, and painful. The nurse suspects that the client has developed phlebitis. Which of the following actions should the nurse take first?
A. Stop the infusion and remove the IV catheter.
The nurse should stop the infusion and remove the IV catheter as soon as possible if phlebitis is suspected. Phlebitis is inflammation of a vein that can be caused by mechanical, chemical, or infectious factors. Potassium chloride is a vesicant medication that can cause severe tissue damage if it extravasates into the surrounding tissues. The nurse should apply a warm compress to the infusion site after removing the IV catheter to reduce inflammation and discomfort. The nurse should notify the provider and obtain an order for a different IV site to continue the infusion of potassium chloride at a different location. The nurse should not slow down the infusion rate and monitor the client because this could worsen the condition and increase the risk of complications.
B. Apply a warm compress to the infusion site.
This is an appropriate action after removing the IV catheter, but not before.
C. Notify the provider and obtain an order for a different IV site.
This is an appropriate action after removing the IV catheter and applying a warm compress, but not before.
D. Slow down the infusion rate and monitor the client.
This is not an appropriate action because it could worsen the condition and increase the risk of complications.
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Full Explanation
The nurse should stop the infusion and remove the IV catheter as soon as possible if phlebitis is suspected. Phlebitis is inflammation of a vein that can be caused by mechanical, chemical, or infectious factors. Potassium chloride is a vesicant medication that can cause severe tissue damage if it extravasates into the surrounding tissues.
The nurse should apply a warm compress to the infusion site after removing the IV catheter to reduce inflammation and discomfort. The nurse should notify the provider and obtain an order for a different IV site to continue the infusion of potassium chloride at a different location. The nurse should not slow down the infusion rate and monitor the client because this could worsen the condition and increase the risk of complications.
b) Incorrect. This is an appropriate action after removing the IV catheter, but not before.
c) Incorrect. This is an appropriate action after removing the IV catheter and applying a warm compress, but not before.
d) Incorrect. This is not an appropriate action because it could worsen the condition and increase the risk of complications.
Similar Questions
A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take to ensure medication safety? (Select all that apply.)
A. Check the medication label against the medication administration record (MAR) three times.
This is one of the methods of ensuring medication safety.
B. Ask the client to state their name and date of birth before giving the medication.
This is another method of ensuring medication safety.
C. Use a barcode scanner to verify the client's identification band and the medication.
This is a third method of ensuring medication safety.
D. Document the medication administration after completing other tasks.
The nurse should document the medication administration as soon as possible after giving the medication, not after completing other tasks.
E. Follow the six rights of medication administration.
This is a general principle of medication safety.
Full Explanation
The nurse should check the medication label against the MAR three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.
The nurse should also ask the client to state their name and date of birth and use a barcode scanner to verify the client's identification band and the medication. These are methods of ensuring that the right medication is given to the right client.
The nurse should follow the six rights of medication administration: right client, right medication, right dose, right route, right time, and right documentation.
The nurse should document the medication administration as soon as possible after giving the medication, not after completing other tasks.
a) Correct. This is one of the methods of ensuring medication safety.
b) Correct. This is another method of ensuring medication safety.
c) Correct. This is a third method of ensuring medication safety.
d) Incorrect. The nurse should document the medication administration as soon as possible after giving the medication, not after completing other tasks.
e) Correct. This is a general principle of medication safety.
A client is receiving a continuous intravenous infusion of heparin for deep vein thrombosis. The nurse notes that the client's activated partial thromboplastin time (aPTT) is above the therapeutic range. Which of the following actions should the nurse take?
A. Stop the infusion and notify the provider.
This is not an appropriate action. Stopping the infusion abruptly could put the client is at risk for clotting and complications such as pulmonary embolism or stroke The nurse should only stop the infusion if instructed by the provider or if the client has signs of severe bleeding or haemorrhage.
B. Decrease the infusion rate and notify the provider.
This is an appropriate action. Decreasing the infusion rate will lowe the heparin dose and bring the aPTT back to the therapeutic range. The nurse should notify the provider of the aPTT result and obtain further orders for heparin therapy.
C. Increase the infusion rate and notify the provider.
This is not an appropriate action. Increasing the infusion rate will rais the heparin dose and increase the aPTT further above the therapeutic range. This could worsen the risk of bleeding for the client.
D. Continue the infusion and monitor the client.
This is not an appropriate action. Continuing the infusion without adjusting the rate or notifying the provider could result in harm to the client due to excessive anticoagulation and bleeding.
Full Explanation
Heparin is an anticoagulant that inhibits clotting factors and prevents thrombus formation. The aPTT is a laboratory test that measures the effectiveness of heparin therapy. The therapeutic range for aPTT is usually 1.5 to 2 times the normal value, which is about 25 to 35 seconds. If the aPTT is above the therapeutic range, this indicates that the client is at risk for bleeding and that the heparin dose is too high.
A) This is not an appropriate action. Stopping the infusion abruptly could put the client is at risk for clotting and complications such as pulmonary embolism or stroke The nurse should only stop the infusion if instructed by the provider or if the client has signs of severe bleeding or haemorrhage.
B) Correct. This is an appropriate action. Decreasing the infusion rate will lower the heparin dose and bring the aPTT back to the therapeutic range. The nurse should notify the provider of the aPTT result and obtain further orders for heparin therapy.
C) This is not an appropriate action. Increasing the infusion rate will raise the heparin dose and increase the aPTT further above the therapeutic range. This could worsen the risk of bleeding for the client.
D) This is not an appropriate action. Continuing the infusion without adjusting the rate or notifying the provider could result in harm to the client due to excessive anticoagulation and bleeding.
A nurse is administering an intramuscular injection to a client. Which of the following actions should the nurse take to prevent medication errors?
A. Use the Z-track method to seal the medication in the muscle.
This is not an action to prevent medication errors, but rather an action to prevent leakage of the medication from the injection site and reduce pain and irritation. The Z-track method involves pulling the skin to one side before inserting the needle and releasing it after withdrawing the needle.
B. Aspirate for blood before injecting the medication.
This is not an action to prevent medication errors, but rather an action to prevent injecting the medication into a blood vessel. Aspiration involves pulling back on the plunger of the syringe before injecting the medication and checking for blood return in the syringe.
C. Massage the injection site after administering the medication.
This is not an action to prevent medication errors, but rather an action to enhance absorption and reduce pain and irritation. Massage involves applying gentle pressure to the injection site after administering the medication.
D. Rotate the injection sites among different muscle groups.
The nurse should rotate the injection sites among different muscle groups to prevent tissue damage, irritation, and absorption problems. The nurse should follow the recommended sites for intramuscular injections, such as the deltoid, ventrolateral, vastus lateralis, and dorsogluteal muscles.
Full Explanation
The nurse should rotate the injection sites among different muscle groups to prevent tissue damage, irritation, and absorption problems. The nurse should follow the recommended sites for intramuscular injections, such as the deltoid, ventrolateral, vastus lateralis, and dorsogluteal muscles.
A) This is not an action to prevent medication errors, but rather an action to prevent leakage of the medication from the injection site and reduce pain and irritation. The Z-track method involves pulling the skin to one side before inserting the needle and releasing it after withdrawing the needle.
B) This is not an action to prevent medication errors, but rather an action to prevent injecting the medication into a blood vessel. Aspiration involves pulling back on the plunger of the syringe before injecting the medication and checking for blood return in the syringe.
C) This is not an action to prevent medication errors, but rather an action to enhance absorption and reduce pain and irritation. Massage involves applying gentle pressure to the injection site after administering the medication.
D) Correct. This is an action to prevent medication errors by avoiding repeated injections in the same muscle group.