需要掌握blanching, coolness, edema
Warm compress, blood return, infiltration
（Strategic word）
Aspiration of the fluid,injection of antidote,elevation of extremities
time intervals
Implement treatment 给于治疗
Agency Protocol的意思是各个机构的常规处理方法
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these fndings, the nurse would implement which action first?
1. Remove the IV. 2. Apply a warm compress. 3. Check for a blood return. 4.Measure the area of infiltration.
Answer: 1 This question requires that you focus on the data in the question and analyze that data to determine that the client is experiencing an infiltration. Note the strategic word,first. Next, you need to consider the harmful effects of infiltration and determine the action to implement first. Because infiltration can be damaging to the surrounding tissue, the appropriate first action is to remove the IV to prevent further damage. Once the IV is removed, further action would be taken, depending on the medication infusing at the time of infiltration and based on agency protocol. Further action may include aspiration of the fluid from the site, injection of an antidote, application of warm or cool compresses for specific time intervals, or elevation of the extremity.
用户评论