Comprehensive NCLEX -RN Review Examination Prep 8th Ed.2021

The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these findings, the nurse should implement which action? 1. Remove the IV. 2. Apply a warm compress. 3. Check for a blood return. 4. Measure the area of infiltration. Answer: 1 This question requires that you focus on the data in the question and determine that the client is experiencing an infiltration. Next, you need to consider the harmful effects of infiltration and determine the action to implement. Because infiltration can be damaging to the surrounding tissue, the appropriate action is to remove the IV to prevent any further damage. Once the IV is removed, further action should be taken depending on the medication infusing at the time of infiltration based on agency protocol, but may include aspiration of the fluid from the site, injection of an antidote, application of warm or cool compresses for specified time intervals, and elevation of the extremity.Management of Care The nurse has received the client assignment for the day. Which client should the nurse assess first? 1. The client who needs to receive subcutaneous insulin before breakfast 2. The client who has a nasogastric tube attached to intermittent suction 3. The client who is 2 days postoperative and is complaining of incisional pain 4. The client who has a blood glucose level of 50 mg/dL (2.8 mmol/L) and complaints of blurred vision