A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Administer an analgesic PO.

Request a prescription for placement of a central venous access device.

Administer a local anesthetic.

Remove the catheter and insert another into a different site.

Answer and Explanation

The Correct Answer is D

A.   Administering an analgesic by mouth (PO) may not provide immediate relief for the pain at the insertion site. It is more effective to address the issue directly by repositioning the IV catheter.
B.   Requesting a prescription for a central venous access device is not necessary in this situation. If peripheral IV access is indicated, the nurse should aim to find a suitable site for insertion.
C.   Administering a local anesthetic may not be necessary if the pain is solely related to the insertion of the IV catheter. Repositioning the catheter to a more comfortable site is a more appropriate first step.
D.   If the client reports pain at the insertion site after the IV catheter has been placed, it may indicate that the catheter is not properly positioned or may be causing discomfort. In this case, it is appropriate for the nurse to remove the catheter and select a different site for insertion.

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Correct Answer is D

Explanation

- A) Elevating the bed to a comfortable position for the nurse is important to prevent strain or injury to the nurse's back. However, this action alone does not ensure the client's safety during the transfer.
- B) While acquiring help can be useful, especially for a heavy client or one with limited mobility, it is not the primary action to ensure safety during the transfer.
- C) Placing the wheelchair at a 90° angle to the bed may make the transfer more difficult because it does not allow for the most direct path to the wheelchair.
- D) Locking the wheels of both the bed and the wheelchair is the correct action to take to ensure stability and prevent movement, providing a safe transfer for the client.

A. right upper sternal border B. left upper sternal border C. left lower sternal border D. 5th intercostal space, midclavicular line

Correct Answer is {"xRanges":[234.765625,254.765625],"yRanges":[107.609375,127.609375]}

Explanation

A. The right upper sternal border is not the correct placement for auscultating the apical pulse. This location is more appropriate for assessing heart sounds related to the aortic valve.
B. The left upper sternal border is not the correct placement for auscultating the apical pulse.
This location is more appropriate for assessing heart sounds related to the pulmonic valve.
C. The left lower sternal border is not the correct placement for auscultating the apical pulse.
This location is more appropriate for assessing heart sounds related to the tricuspid valve.
D. 5th intercostal space, midclavicular line is the correct placement for auscultating the apical pulse. This location corresponds to the apex of the heart, which is where the apical pulse (also known as the point of maximum impulse or PMI) can be best heard.

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A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is {"xRanges":[234.765625,254.765625],"yRanges":[107.609375,127.609375]}

Explanation

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