Difficulty: Medium
Average Score: 90%
Simulated
Passage / Scenario
The following scenario applies to the next 1 itemsThe nurse in the intensive care unit (ICU) has completed an assessment on a client
Item 1 of 1
Nurses' Notes Orders
1923: Assessment completed. Peripheral vascular access device (PAD) was assessed. Erythema
and swelling were noted at the insertion site. The client reported "severe" pain, and
tenderness was endorsed when it was palpated. The infusion was stopped.
The nurse reviews the assessment and is preparing to take action. For each potential action, click to specify whether the potential action is indicated or not indicated for the client.
Correct answer
A,C,F
Rationale
Removing the PVAD, notifying the physician, and disconnecting the administration set are indicated for infiltration; flushing is not indicated, and phentolamine is for extravasation.