The nurse is assessing the client with an IV line. The nurse ...

[faduma]

The nurse is assessing the client with an IV line. The nurse notes that the IV insertion site is red, edematous, and painful. The nurse's first action should be to:
 
  1. Immediately discontinue the IV line and remove the cannula
  2. Put cool compresses on the IV site to decrease the edema
  3. Notify the health care provider of the situation
  4. Put warm compresses on the IV site to decrease the pain

Question 2

Which of the following clients is most at risk for fluid volume deficit?
 
  1. 25-year-old male near-drowning victim
  2. 56-year-old woman with salicylate poisoning
  3. 45-year-old woman with second-degree burns over 20 of her body
  4. 13-year-old boy with an oral temperature of 103.4 F

[paavo]

Answer to Question 1

ANS: 3
The nurse should notify the health care provider to determine if the health care provider would like to culture the IV cannula. (Confirm before removal of IV line.) Wrapping the extremity in a warm, moist towel for 20 minutes promotes venous return, increases circulation, and reduces pain and edema. Heat therapy can be repeated three to four times during the day.

Answer to Question 2

ANS: 3
The greater the body surface burned, the greater the fluid loss. The burned client loses body flu-ids by one of five routes. First, plasma leaves the intravascular space and becomes trapped ede-ma. This is also called the plasma-to-interstitial fluid shift. It is accompanied by a loss of serum proteins. Second, plasma and interstitial fluids are lost as burn exudate. Third, water vapor and heat are lost in proportion to the amount of skin that is burned. Fourth, blood leaks from dam-aged capillaries, adding to the intravascular fluid volume loss. Finally, sodium and water shift into the cells, further compromising extracellular fluid volume. A near-drowning victim may suf-fer from hypoxia and respiratory acidosis but would not be as likely to be at risk for fluid volume deficit as the burn victim. Salicylate poisoning may cause some insensible fluid loss through the body's hyperventilation to compensate for the increased PaCO2. Adolescents have increased metabolic processes and increased water production because of the rapid changes that occur in the anatomical and physiological process.

[faduma]

Excellent

[nguyenhoanhat]

Gracias!