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. Raise the bed to a comfortable height:
Raising the bed to a comfortable height is essential for proper body mechanics and preventing back strain. It ensures the nurse can perform the procedure efficiently and safely.

B. Stand on the left side of the bed:
While a left-handed nurse might prefer to stand on the left side for better access, this choice depends on the room layout and client position. Standing on the side where the nurse is most comfortable is essential, but it is not the primary action compared to ensuring proper bed height.

C. Raise the side rail on the working side of the bed:
Raising the side rail on the working side of the bed could obstruct the nurse's access to the client and is not generally recommended during procedures requiring close access to the client.

D. Use the non-dominant hand to insert the catheter:
The dominant hand, in this case, the left hand, should be used to insert the catheter for better control and precision. The non-dominant hand is typically used to hold the genitalia and provide stability.

A. Flushed skin B. Fever C. Nausea and vomiting D. Extreme thirst

Correct Answer is C

Explanation

A) Flushed skin: Flushed skin is not typically associated with hyponatremia. Instead, hyponatremia may present with symptoms such as pallor or cool, clammy skin due to alterations in perfusion and fluid balance.

B) Fever: Fever is not a common manifestation of hyponatremia. Elevated body temperature is typically associated with conditions such as infection or inflammation rather than electrolyte imbalances like hyponatremia.

C) Nausea and vomiting: Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to neurological symptoms, including nausea and vomiting. These symptoms occur due to alterations in osmotic pressure and cellular swelling resulting from the relative excess of water compared to sodium in the extracellular fluid. Other neurological symptoms of hyponatremia can include headache, confusion, lethargy, and seizures.

D) Extreme thirst: Extreme thirst, or polydipsia, is more commonly associated with hypernatremia, which is characterized by a serum sodium level above 145 mEq/L. Hypernatremia results from dehydration or a deficit of body water relative to sodium, leading to increased thirst as the body attempts to restore fluid balance.

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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

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