A nurse is caring for a patient who is receiving pain medication through a saline lock. After flushing the patient's peripheral IV and obtaining a good blood return, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm and tender to the touch. What is the nurse's initial action?

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Question 1 of 5

A nurse is caring for a patient who is receiving pain medication through a saline lock. After flushing the patient's peripheral IV and obtaining a good blood return, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm and tender to the touch. What is the nurse's initial action?

Correct Answer: A

Rationale: The patient has phlebitis; the initial nursing action is do not administer the medication. The medication should not be given slowly. A cool or warm compress may be used later depending upon protocol, but it is not the first action.

Question 2 of 5

A child weighs 22.4 kg, and the prescription is for 24 mg/kg of body weight. The medication comes at the strength of 50 mg/mL. How many mL (to one decimal place) of the medication should the child receive?

Correct Answer: D

Rationale: Dose = 22.4 kg × 24 mg/kg = 537.6 mg. Volume = 537.6 mg ÷ 50 mg/mL = 10.752 mL, rounded to 10.8 mL (one decimal place).

Question 3 of 5

A patient has had a myocardial infarction involving a large section of the heart muscle. You assess them at risk for

Correct Answer: B

Rationale: A large myocardial infarction impairs heart pumping, leading to cardiogenic shock due to inadequate cardiac output.

Question 4 of 5

Prescription labels may be altered by:

Correct Answer: D

Rationale: Only pharmacists can alter prescription labels legally. Staff, administrators, or residents altering labels compromises safety and legality.

Question 5 of 5

In order to crush a medication, you must have:

Correct Answer: B

Rationale: A physician's order is required to crush medications to ensure it's safe (e.g., not enteric-coated) and appropriate for the resident.

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