a nurse assessing a clients iv catheter insertion site notes a hematoma which of the following actions should the nurse take select all that apply
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Nursing Elites

ATI RN

ATI Proctored Pharmacology 2023

1. When a nurse assesses a client's IV catheter insertion site and notes a hematoma, which of the following actions should the nurse take? (Select all that apply.)

Correct answer: C

Rationale: When a nurse detects a hematoma at the IV catheter insertion site, applying warm compresses is beneficial as it can promote healing by enhancing circulation and reducing swelling. Elevating the client's arm helps in reducing edema, which can relieve pressure, pain, and further bleeding in the hematoma area. Stopping the infusion may be necessary in certain situations, but it is not a standard action for all hematoma cases. Applying alcohol to the insertion site is discouraged as it can cause irritation and may not aid in resolving the hematoma.

2. A client has a new prescription for Nitroglycerin to treat angina. Which of the following instructions should be included?

Correct answer: C

Rationale: When using Nitroglycerin patches to treat angina, it is crucial to apply the patch to a different site each time. This practice helps prevent skin irritation and ensures proper absorption of the medication, optimizing its effectiveness in managing angina symptoms.

3. A client has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction for a client using nitroglycerin transdermal patches is to remove the patch every night before bedtime. This practice helps prevent tolerance to the medication's effects. Continuous exposure to nitroglycerin can result in the body becoming less responsive to its therapeutic effects over time, reducing its efficacy in managing the prescribed condition. Choices A, C, and D are incorrect. Applying the patch to a different location each day does not address the issue of tolerance. Massaging the patch area gently after application is not recommended as it may alter drug absorption. Shaving the area before applying the patch is unnecessary and may increase the risk of skin irritation.

4. A nurse is teaching a client who has a new prescription for Atenolol. Which of the following adverse effects should the nurse instruct the client to monitor?

Correct answer: C

Rationale: Atenolol is a beta-blocker that can cause bradycardia as an adverse effect. The client should monitor their pulse regularly and report any significant decreases.

5. What is the pharmacological class of Lithium?

Correct answer: B

Rationale: Lithium is classified as a mood stabilizer due to its primary use in managing bipolar disorder, where it helps stabilize mood swings and prevent episodes of mania and depression. While it can have other effects on the body, its main therapeutic role lies in its mood-stabilizing properties. Choices A, C, and D are incorrect as lithium is not classified as antidiabetics, biguanides, antiarrhythmics, anticonvulsants, or vascular headache suppressants. Its main pharmacological class is mood stabilizers.

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