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 B

No explanation

A. Affirm that the client should rise slowly from the chair. B. Tell the UAP to assist the client in moving more quickly. C. Demonstrate how to help the client move more efficiently. D. Offer a PRN analgesic to reduce painful movement.

Correct Answer is A

Explanation

A) Correct- Clients with Parkinson's disease often experience bradykinesia and impaired mobility. Rising slowly from a seated position is important to prevent falls and maintain stability. Affirming the correct movement strategy promotes the client's safety.
B) Incorrect- Telling the UAP to make the client move more quickly could be unsafe and not appropriate for a client with Parkinson's disease. Rapid movements might lead to balance issues or falls.
C) Incorrect- While demonstrating proper technique might be helpful, it's not the most immediate action the nurse should take. The client's safety and well-being are the priority.
D) Incorrect- Painful movement is not the primary issue here. The client's movement is slow due to Parkinson's disease, and this is expected.

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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

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