The student nurse is preparing to administer an IV bolus medication through a small-gauge IV catheter. The student notes that there is no blood return on aspiration. Which action by the student should the nursing instructor question?
a. Checking the IV site for redness and swelling
b. Immediately stopping the IV infusion and removing the IV catheter
c. Checking to see if the IV is infusing without difficulty
d. Injecting the IV medication if no signs of infiltration
B
The student should stop the IV, remove the catheter, and start a new one only if the line is not patent. In some cases, especially with a smaller-gauge IV catheter, blood return is not always aspirated, even if the IV is patent. Confirm patency. If the IV site does not show signs of infiltration and the IV fluid is infusing without difficulty, give the IV bolus medication.
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Which are appropriate interventions for the nurse to include in the plan of care for a child who is receiving traction? Select all that apply
1. Monitoring breath sounds 2. Assessing neurovascular status every 2 hours 3. Repositioning every 2 to 3 hours 4. Using moleskin to protect the skin from rough edges 5. Encouraging the parents cuddle with their child