A hospice client is being cared for by the nurse at home. The client begins to experience changes in respirations, coughing and becoming increasingly restless. Based on these clinical manifestations, the nurse would implement which of the following interventions? (SELECT ALL THAT APPLY) ( Medical orders are active for each intervention that would require a medical order.)

Call for transportation to the hospital

Initiate low-flow oxygen per nasal cannula

Provide relief from pain and from other distressing symptoms

Place the bed in semi-Fowler's position

Administer anti-anxiety medications as needed

Answer and Explanation

Correct Answer : C,D

C. Providing relief from pain and other distressing symptoms is a fundamental aspect of hospice care. The nurse should assess the client's pain level and other symptoms such as dyspnea, coughing, and restlessness, and intervene accordingly. This may involve administering analgesics, antitussives, or other medications as appropriate to alleviate discomfort and promote comfort and quality of life.
D. Placing the bed in semi-Fowler's position (with the head of the bed elevated) can help improve respiratory mechanics, ease breathing, and reduce respiratory distress in clients experiencing dyspnea. This position allows for better lung expansion and can facilitate the drainage of respiratory secretions, thereby promoting comfort and alleviating symptoms. This intervention does not typically require a medical order and can be implemented by the nurse based on clinical assessment.
A. Calling for transportation to the hospital may not be necessary or appropriate in this situation, especially considering that the client is under hospice care and experiencing changes in respiratory status and restlessness, which could be indicative of end-of-life processes. Hospice care focuses on providing comfort and symptom management in the home setting, and hospitalization may not align with the client's goals of care at this stage.
B. Initiating low-flow oxygen per nasal cannula may be appropriate to provide comfort and relieve hypoxia if the client is experiencing respiratory distress. However, this intervention would typically require a medical order, as oxygen therapy should be prescribed based on assessment findings and clinical indications.
E. Administering anti-anxiety medications may be considered if the client is experiencing significant anxiety or agitation that is distressing and impacting their comfort. However, the decision to administer anti-anxiety medications should be based on thorough assessment and consideration of the client's overall condition, goals of care, and potential risks and benefits. This intervention would typically require a medical order.

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Correct Answer is A

Explanation

A. Infiltration occurs when the intravenous solution leaks into the surrounding tissue instead of flowing into the vein. This can cause discomfort, swelling, and potential tissue damage. Stopping the infusion immediately helps prevent further infiltration and minimizes the risk of complications such as tissue necrosis or damage.
B. While documenting the findings is important for the client's medical record, it is not the first action to take when suspecting infiltration. Immediate intervention to stop the infusion and assess the site for complications takes precedence over documentation.
C. Flushing the catheter with normal saline may be necessary after stopping the infusion to ensure patency and clear any remaining solution from the catheter. However, this step should follow the immediate cessation of the infusion to prevent further infiltration.
D. Removing the catheter may be necessary if significant infiltration has occurred or if there are signs of tissue damage. However, this should be done after stopping the infusion to prevent further infiltration and should be based on the assessment findings and healthcare provider's instructions.

A. eliminate the hourly assessment of the IV site. B. prevent accidental delivery of large amounts of fluids. C. control the drip rate based on the position of the client. D. administer IV fluids at a rapid rate.

Correct Answer is B

Explanation

B. One of the primary functions of an IV infusion pump is to precisely control the rate and volume of fluid delivery, thereby reducing the risk of accidental administration of large amounts of fluids. The pump allows for accurate programming of infusion rates and volume limits, enhancing safety and preventing fluid overload or other complications.
A. Using an IV infusion pump does not eliminate the need for assessing the IV site regularly. Regardless of the infusion method, it is essential to monitor the IV site frequently for signs of complications such as infiltration, phlebitis, or dislodgement. Therefore, this option is not the appropriate rationale for using an IV infusion pump.

C. IV infusion pumps are programmable devices that allow for precise control of the drip rate independent of the client's position. They ensure a consistent and controlled flow rate regardless of changes in the client's position, providing reliable delivery of fluids or medications.
D. While IV infusion pumps can deliver fluids at various rates, including rapid infusion rates when necessary, their primary purpose is not to administer fluids at a rapid rate. Rather, they are designed to deliver fluids or medications at controlled and programmed rates tailored to the client's needs, ensuring safety and accuracy.

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Naxlex Comprehensive Predictor Exams

The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?

Correct Answer is A

Explanation

The nurse recognizes that the appropriate rationale for using an IV infusion pump for a client is to:

Correct Answer is B

Explanation

A client is receiving an intravenous (IV) solution over a short amount of time to replace volume losses. The nurse understands that this IV solution is most likely to be:

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