A client is receiving an infusion of amiodarone (Cordarone), and the nurse notes that the client's arm has begun to blister around the IV site. This manifestation is consistent with which condition?
a. Extravasation
b. Infiltration
c. Infection
d. Phlebitis
A
Certain medications, including amiodarone, vancomycin, and ciprofloxacin, are venous irritants that can cause tissue sloughing and necrosis if the IV infiltrates. The other three complications are possible with any infusion and are not specific to amiodarone.
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An elderly patient with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for:
A) Hypoglycemia B) Fluid volume excess C) Aspiration D) Constipation
The nurse delegates bed making to the unlicensed assistive personnel (UAP). Which client's bed should be made by the nurse and not the UAP?
1. The postoperative client diagnosed with dementia on complete bed rest 2. The client who is diagnosed with myocardial infarction who has bathroom privileges 3. The client with increased intracranial pressure on complete bed rest 4. The postoperative client
The 75-year-old patient complains to the nurse that although she has cleaned her ears with cotton-tipped applicators for weeks, she still can't hear her TV unless it is turned up loud, and she misses a great deal of conversations
On examination of the ears, the nurse antici-pates that there will be: 1. otitis externa. 2. purulent drainage. 3. dry cerumen across the canal. 4. a pearly tympanic membrane.
When checking laboratory values, the nurse notes the client's platelet count is 100,000 mm3. The nurse should include which of the following actions in the client's plan of care?
A) Encourage client to increase ambulation to prevent a deep venous thrombosis. B) Instruct client to increase intake of vitamin C to assist in blood coagulation. C) Hold pressure over injection sites to ensure clotting has occurred. D) Use strict sterile technique with wound care in order to prevent infection.