A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take?

Apply a warm compress to the IV site.

Remove the IV saline lock.

Inject the solution more slowly while flushing the IV saline lock.

Apply firm pressure to the plunger of the syringe during the NV flush to improve patency.

Answer and Explanation

The Correct Answer is B

A. Apply a warm compress to the IV site: While warm compresses can sometimes help alleviate discomfort associated with certain IV complications, such as phlebitis or infiltration, they should not be applied until the cause of the pain is identified. In this case, removing the IV saline lock is the priority action to assess the site properly.

B. Remove the IV saline lock: Pain above the catheter site during flushing may indicate infiltration or phlebitis, both of which require intervention. Removing the IV saline lock allows the nurse to assess the site for signs of complications such as swelling, redness, or coolness to the touch. Once removed, the nurse can then determine the appropriate course of action, such as reinserting the IV at a different site, applying warm compresses, or notifying the healthcare provider if further evaluation or treatment is necessary.

C. Inject the solution more slowly while flushing the IV saline lock: Injecting the solution more slowly may reduce discomfort during flushing, but it does not address the underlying cause of the pain. If there is infiltration or another issue with the IV site, continuing to flush slowly could exacerbate the problem.

D. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency: Applying firm pressure to the plunger of the syringe during flushing is not appropriate when the client reports pain above the catheter site. This action could potentially force fluid into surrounding tissues, worsening infiltration or causing additional discomfort. It is essential to address the pain and assess the IV site before attempting to flush the saline lock again.

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Correct Answer is A

Explanation

A. Propranolol is a beta-blocker medication commonly used to treat hypertension, angina, and certain heart rhythm disorders. However, it is contraindicated in clients with a history of asthma or other obstructive airway diseases due to its potential to cause bronchoconstriction and exacerbate respiratory symptoms.

B. Migraines:
Propranolol is actually commonly used for the prophylactic treatment of migraines, particularly in individuals with frequent or severe migraines. It helps reduce the frequency and severity of migraine attacks by blocking the release of certain chemicals in the brain.

C. Glaucoma:
Propranolol can be used in the treatment of glaucoma, particularly when other treatments have been ineffective. It works by reducing intraocular pressure, which can help prevent vision loss associated with glaucoma.

D. Depression:
Propranolol is not contraindicated in clients with depression. In fact, it may sometimes be used off-label to manage certain symptoms of anxiety or performance anxiety. However, it is important to monitor clients with depression closely when prescribing propranolol, as it may interact with other medications used to treat depression or worsen certain depressive symptoms.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30" to 45". D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.

B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.

C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.

D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.

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A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

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