A client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge intravenous (IV) catheter with normal saline is infusing at a rate of 150 mL/hour. Which intervention should the nurse implement first?

Establish a second IV site.

Stop the normal saline infusion.

Assess the IV for blood return. D. Discontinue the 24 gauge IV.

Answer and Explanation

The Correct Answer is B

A)   Incorrect- While a second IV site might be considered if the first one is causing significant discomfort, it's not the initial intervention. The nurse should first address the immediate concern of pain.
B)   Correct- Pain at the IV site during infusion might indicate infiltration or irritation. Stopping the infusion is the most immediate intervention to prevent further discomfort and potential complications like tissue damage.
C)   Incorrect- While assessing for blood return is important to ensure proper IV placement, it's not the initial intervention for managing pain caused by the infusion.
D)   Incorrect- Discontinuing the IV might be considered if the pain is severe and unmanageable, but the nurse should initially try to address the discomfort without removing the IV.

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Correct Answer is ["A","B","D"]

Explanation

They are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site, and secure it with paper tape after removing the saline lock.

A. A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath. B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness. C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground. D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

Correct Answer is A,B,C,D

Explanation

This client has the highest priority, as he or she may be experiencing an acute asthma attack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.

B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.

This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.

C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground.

This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inﬂammation.

D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.

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A client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge intravenous (IV) catheter with normal saline is infusing at a rate of 150 mL/hour. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is A,B,C,D

Explanation

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