The nurse notes an edematous area around the insertion site of an IV that is cool to the touch and the skin of which appears blanched. Based on these assessment findings, what is the first priority of the nurse?
a. Apply warm compresses to the area
b. Notify the charge nurse
c. Stop the infusion
d. Reposition the arm to improve the fluid flow
ANS: C
The infusion should be stopped and restarted in another location. Warm compresses are contraindicated. Repositioning the arm will not remedy the infiltration. The charge nurse can be notified after the fact.
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What should the initial action of a nurse be when providing first aid to a person with spontaneous epistaxis?
a. Apply direct pressure for 3 to 5 minutes. b. Have the person sit down and lean for-ward. c. Have the person lie down and apply an ice pack. d. Have the person clear the nasal passages by blowing the nose.
Which of the following interventions is used to prevent falls in a health care agency?
A) Display the phone number for the nurses' station. B) Read label directions. C) Keep the environment tidy. D) Keep electrical cords under the bed.
The nurse has administered sumatriptan (Imitrex) to a client. Which effects should the nurse monitor the patient for?
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