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 B
Explanation
Answer: B. The padding of the restraints is against the client's bony prominences.
A. The nurse can insert one finger between the client's wrist and the restraint.
The proper guideline is that the nurse should be able to insert two fingers between the client's wrist and the restraint. This ensures the restraint is snug but not too tight, which helps prevent impaired circulation and skin breakdown.
B. The padding of the restraints is against the client's bony prominences.
This is the correct practice. The padding of the restraints should always be applied to protect the client’s skin and prevent injury, particularly over bony prominences where the risk of pressure sores or skin breakdown is higher.
C. The AP ties the straps of the restraints in a double knot.
A double knot should not be used because it can make it difficult to quickly release the restraint in an emergency. A quick-release knot should always be used to ensure the restraint can be removed easily and promptly if needed.
D. The AP ties the restraints to the side rails.
Restraints should never be tied to movable parts like side rails, as raising or lowering the side rails could cause injury. Restraints should be secured to a part of the bed frame that does not move to prevent harm to the client.
Correct Answer is B
Explanation
A) Utilitarianism: Utilitarianism focuses on the greatest good for the greatest number of people. In this scenario, the nurse's decision not to administer the pain medication is not based on maximizing overall benefit but rather on avoiding harm to the individual client.
B) Non-maleficence: Non-maleficence is the ethical principle of doing no harm. The nurse's decision not to administer the pain medication is rooted in the desire to avoid causing harm to the client by potentially hastening their death.
C) Fidelity: Fidelity refers to the obligation to fulfill commitments and responsibilities. While important, fidelity is not directly relevant to the nurse's decision in this scenario.
D) Veracity: Veracity refers to truthfulness and honesty. While honesty is crucial in communicating with the client and their family about their condition and care, it is not the primary ethical principle guiding the nurse's decision in this situation.
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