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NURS 428 Hesi/saunders online review for NCLEX MODULE 8 Exam Questions With Rationales

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NURS 428 Hesi/saunders online review for NCLEX MODULE 8 Exam Questions With Rationales 1.A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, ... and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first?  Remove the IV catheter Correct  Slow the rate of infusion  Notify the health care provider  Check for loose catheter connections Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be indicated by client discomfort at the site or by redness, warmth, and swelling in the area of the catheter. The IV catheter should be removed and a new IV line inserted at a different site. Slowing the rate of infusion and checking for loose catheter connections are not correct responses. The health care provider would be notified if phlebitis were to occur, but this is not the initial action. 2. A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first?  Remove the IV  Sit the client up in bed  Shut off the IV infusion Correct  Slow the rate of infusion Rationale: The client’s symptoms are indicative of speed shock, which results from the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note that 400 mL has infused over 60 minutes. The first action on the part of the nurse is shutting off the IV infusion. Other actions may follow in rapid sequence: The nurse may elevate the head of the bed to aid the client’s breathing and then immediately notify the health care provider. Slowing the infusion rate is inappropriate because the client will continue to receive fluid. The IV does not need to be removed. It may be needed to manage the complication. [Show More]

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