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) Cheyne-Stokes respirations:
Cheyne-Stokes respirations are characterized by a cycle of gradually increasing and then decreasing respirations followed by a period of apnea. This pattern repeats in a regular cycle. It is commonly observed in clients with conditions affecting the central nervous system, such as traumatic brain injury, stroke, or brain tumors. Cheyne-Stokes respirations can also occur during the dying process. The alternating periods of hyperventilation and apnea result from fluctuations in oxygen and carbon dioxide levels in the blood.

B) Kussmaul respirations:
Kussmaul respirations are deep, rapid, and labored breathing patterns often observed in clients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.

C) Apneustic respirations:
Apneustic respirations are characterized by prolonged inspiratory gasps followed by insufficient expiration. This irregular breathing pattern typically indicates damage to the pons, a part of the brainstem involved in regulating breathing. Apneustic respirations are different from the pattern described in the scenario.

D) Stridor:
Stridor is a high-pitched, noisy respiratory sound heard on inspiration that indicates upper airway obstruction, such as from swelling, foreign body aspiration, or tumors. It is not associated with the alternating pattern of hyperventilation and apnea described in Cheyne-Stokes respirations.

A. 36% B. 70% C. 50% D. 28%

Correct Answer is D

Explanation

D. 28%:

When a client receives oxygen via a nasal cannula at a flow rate of 2 L/min, the approximate inspired oxygen concentration is around 24-28%. This is because each liter of oxygen delivered through a nasal cannula adds approximately 4% to the baseline room air concentration of 21%. Therefore, at 2 L/min, the client would be receiving approximately 24-28% inspired oxygen concentration.

A. 36%, B. 70%, C. 50%:

These percentages are not consistent with the oxygen concentration delivered via a nasal cannula at 2 L/min. Higher flow rates or alternative oxygen delivery systems, such as masks or high-flow nasal cannula, would be needed to achieve these concentrations.

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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?

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