A patient who is receiving a final dose of intravenous (IV) cephalosporin begins to complain of pain and irritation at the infusion site. The nurse observes signs of redness at the IV insertion site and along the vein
What is the nurse's priority action? a. Apply warm packs to the arm, and infuse the medication at a slower rate.
b. Continue the infusion while elevating the arm.
c. Select an alternate intravenous site and administer the infusion more slowly.
d. Request central venous access.
C
These signs indicate thrombophlebitis. The nurse should select an alternative IV site and admi-nister the infusion more slowly. The IV should not be continued in the same site, because necro-sis may occur. A central line would be indicated only for long-term administration of antibiotics.
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A patient who has suffered a spinal cord injury at C4 is experiencing a sudden change in condition. His BP is 186/101; heart rate is 45; and he is profusely sweating and complaining of "not feeling right." The nurse should
A) call a "Code Blue." B) page physician stat. and ask for an antihypertensive medication. C) palpate his bladder for overdistention. D) place his bed flat and elevate the foot of the bed.
An older adult client has been voluntarily admitted for treatment of alcohol dependency. In im-plementing care, the nurse plans which intervention based upon knowledge about alcohol and aging?
a. Assessing the client for both depression and anxiety b. Discussing the poor prognosis of this dis-order with the client c. Explaining the need for proper nutrition to minimize the effects of alcoholism d. Identifying the effects of chronic alcohol-ism on the human body
Which measurement is not indicated for a 4-year-old well-child examination?
a. Blood pressure b. Weight c. Height d. Head circumference
The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dl to 16.6 mg/dl in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn?
1. Continue to observe. 2. Begin phototherapy. 3. Begin blood exchange transfusion. 4. Stop breastfeeding.