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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.
Correct Answer is ["A","B","D","E"]
Explanation
A) Correct - Demonstrating the technique used to monitor blood glucose levels is crucial.
Incorrect technique can lead to inaccurate readings, impacting insulin dosing decisions and blood sugar control.
B) Correct - Some asthma medications, like corticosteroids, can elevate blood glucose levels.
Evaluating the client's asthma medications is essential as they can contribute to fluctuations in blood sugar levels.
C) Incorrect- Asking the client if they want a different manufacturer's glucose monitoring device is not helpful, because it does not address the underlying causes of the poor glycemic control. The client may also perceive this as a lack of confidence in their ability to manage their diabetes or as a criticism of their choice of device. The nurse should focus on educating the client on how to use their current device correctly and consistently, rather than suggesting a change that may not be necessary or feasible.
D) Correct - Understanding the client's daily routine helps identify factors influencing blood glucose control, such as meal timing, activity level, and stress. This information aids in creating a personalized diabetes management plan.
E) Correct - Ensuring the client uses a new insulin needle for each administration is important for preventing infection and complications. Reusing needles can affect injection site health and insulin absorption.
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