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 D

Explanation

A) Disenfranchised grief:
Disenfranchised grief occurs when a person's loss is not socially recognized or supported, such as the death of a pet or an ex-spouse. The client's situation does not indicate disenfranchised grief.

B) Anticipatory grief:
Anticipatory grief happens before an impending loss, such as when a loved one is terminally ill. The client is grieving after the loss, not before it.

C) Prolonged grief:
Prolonged grief, also known as complicated grief, involves intense, persistent, and disabling grief symptoms that interfere with normal functioning. The client’s decreasing grief and positive outlook indicate that they are not experiencing prolonged grief.

D) Uncomplicated grief:
Uncomplicated grief, also known as normal grief, is the natural response to loss. It includes a range of emotions and reactions that typically diminish over time as the individual adapts to the loss. The client’s decreasing grief severity and forward-looking attitude towards spending time with their grandchildren are characteristic of uncomplicated grief.

A. Helping the client select a low-salt diet B. Administering oxygen via nasal cannula at 2 Umin C. Encouraging the client to drink 2 to 3 L of water daily D. Maintaining a semi-Fowler's position as often as possible

Correct Answer is C

Explanation

A. Helping the client select a low-salt diet:
This option is not directly related to addressing tenacious bronchial secretions in COPD. While a low-salt diet may be beneficial for managing conditions like hypertension or heart failure, it does not directly influence the viscosity of bronchial secretions.

B. Administering oxygen via nasal cannula at 2 L/min:
Oxygen therapy is important for clients with COPD, especially during exacerbations or periods of hypoxemia. However, in this scenario, the client's primary concern is tenacious bronchial secretions, and oxygen therapy alone may not effectively address this issue.

C. Encouraging the client to drink 2 to 3 L of water daily:
This is the correct answer. Increasing fluid intake helps to hydrate the mucous membranes and thin bronchial secretions, making them easier to expectorate. Adequate hydration is essential for optimizing the clearance of secretions in clients with COPD.

D. Maintaining a semi-Fowler's position as often as possible:
While maintaining a semi-Fowler's position can improve respiratory mechanics and reduce dyspnea in clients with COPD, it does not directly address the issue of tenacious bronchial secretions. This position primarily helps in optimizing lung expansion and facilitating easier breathing.

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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

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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