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) Headache:
Clients with obstructive sleep apnea often experience morning headaches due to the intermittent hypoxia and hypercapnia that occur during episodes of apnea. These headaches are typically described as dull and diffuse and may improve throughout the day.

B) Nausea:
While gastrointestinal symptoms such as nausea can occur in some individuals with sleep apnea, it is not a typical or specific finding associated with this condition. Nausea may result from other causes, such as medication side effects or underlying gastrointestinal issues, rather than directly from obstructive sleep apnea.

C) Hypotension:
Obstructive sleep apnea is more commonly associated with hypertension rather than hypotension. The recurrent episodes of hypoxemia and sympathetic nervous system activation during apneic episodes can lead to systemic hypertension over time.

D) Constipation:
Constipation is not a typical finding associated with obstructive sleep apnea. While sleep apnea may contribute to fatigue and alterations in gastrointestinal motility in some individuals, constipation is not a direct consequence of this sleep disorder.

A. Viral infection B. Increased cognitive awareness C. Hypotension D. Increased energy

Correct Answer is A

Explanation

A) Viral infection:
Chronic stress can suppress the immune system, making individuals more susceptible to infections, including viral infections. Prolonged stress can dysregulate the immune response, leading to increased vulnerability to various illnesses.

B) Increased cognitive awareness:
Chronic stress often impairs cognitive function rather than enhancing it. It can lead to difficulties with concentration, memory problems, and cognitive fatigue due to the continuous activation of the body's stress response system.

C) Hypotension:
Chronic stress typically leads to increased blood pressure rather than hypotension. Stress activates the sympathetic nervous system, resulting in the release of stress hormones like cortisol and adrenaline, which can elevate blood pressure over time.

D) Increased energy:
While acute stress can trigger a temporary surge in energy due to the release of stress hormones, chronic stress often leads to fatigue and exhaustion. Prolonged activation of the stress response system can deplete energy reserves and disrupt sleep patterns, resulting in feelings of fatigue and lethargy.

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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

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