Questions 118

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NCLEX RN Medical Surgical Practice Questions Questions

Extract:

The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) has completed an assessment on a client
Item 1 of 1
Nurses' Notes Orders
1923: Assessment completed. Peripheral vascular access device (PAD) was assessed. Erythema
and swelling were noted at the insertion site. The client reported "severe" pain, and
tenderness was endorsed when it was palpated. The infusion was stopped.


Question 1 of 5

The nurse reviews the assessment and is preparing to take action. For each potential action, click to specify whether the potential action is indicated or not indicated for the client.

Potential Action Indicated Not indicated
Remove the peripheral vascular access device
Obtain an order for phentolamine
Notify the physician
Flush the intravenous vascular access device with 5 mL of 0.9% saline (sodium chloride)
Disconnect administration set

Correct Answer: A,C,F

Rationale: Removing the PVAD, notifying the physician, and disconnecting the administration set are indicated for infiltration; flushing is not indicated, and phentolamine is for extravasation.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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