Summary Saunders Comprehensive Review for the NCLEX-RN® Examination

Level of Cognitive Ability: Applying 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. Client Needs The NCSBN identifies a test plan framework based on Client Needs, which includes 4 major categories. Some of these categories are divided further into subcategories. The Client Needs categories are Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity (Table 1-2). Table 1-2 Client Needs Categories and Percentage of Questions on the