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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) The client's hand is cool and pale: A cool and pale hand suggests decreased circulation, which could be due to the restraint being too tight and impeding blood flow. Loosening the restraint can improve circulation and prevent complications such as tissue damage or nerve injury.
B) The client has full range of motion in her wrist: While it's important to ensure that the client can move comfortably within the restraint to prevent stiffness and maintain circulation, full range of motion alone may not necessitate loosening the restraint. However, if the client's movements are restricted or uncomfortable due to the tightness of the restraint, loosening may be necessary.
C) The client is attempting to remove the restraint: This indicates that the restraint may be too loose or improperly applied, allowing the client to manipulate it easily. The nurse should assess the fit of the restraint and adjust it as needed to prevent the client from removing it while still ensuring safety and appropriate immobilization.
D) The client has a capillary refill of less than 2 seconds: While a rapid capillary refill indicates good circulation, it alone may not warrant loosening the restraint. However, if the client experiences discomfort or other signs of impaired circulation despite rapid capillary refill, the restraint may need adjustment to alleviate pressure and improve circulation.
Correct Answer is A
Explanation
A) "You will have control of administering your own pain medication":
This statement accurately describes the function of a PCA (Patient-Controlled Analgesia) device, where the client has control over administering their own pain medication within preset limits. Empowering the client to manage their pain helps promote autonomy and individualized pain management.
B) "The pain medication is delivered into your muscle":
This statement is incorrect because PCA devices typically deliver medication intravenously, not into the muscle. It's important for the client to understand the route of administration to use the device effectively and safely.
C) "Your partner can push the PCA button for you if you are asleep":
Allowing someone else to activate the PCA button for the client can lead to overmedication and is not recommended. PCA devices are designed for the client to self-administer medication based on their own pain experience and need.
D) "A large dose of pain medication is given with each injection":
This statement is inaccurate because PCA devices are programmed to deliver a controlled dose of medication with each activation, usually within safe limits set by the healthcare provider. The doses are typically set to avoid overdosing while providing effective pain relief.
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