The client's IV. placed near the right antecubital space, is running very slowly but does not appear infiltrated and does not have evidence of phlebitis. Which measure should the nurse implement to attempt to improve the flow rate of the IV?

Alter the client's arm position

Place the IV on an infusion pump

Lower the height of the IV pole

Open the clamp as far as possible for one hour

Answer and Explanation

The Correct Answer is A

A. Changing the client's arm position, such as raising or lowering it, could potentially improve flow by altering the gravitational pull on the IV solution. For example, raising the arm could increase flow due to increased pressure, while lowering it could decrease flow. However, this approach may not always be effective and should be done cautiously to avoid discomfort or compromising the integrity of the IV site.
B. Using an infusion pump can help regulate the flow rate of the IV solution more accurately compared to gravity alone. However, if the IV is running slowly due to factors unrelated to the infusion rate setting, such as a partial blockage or resistance in the IV line, using an infusion pump may not necessarily improve the flow rate.
C. Lowering the height of the IV pole can increase the gravitational force acting on the IV solution, potentially improving flow. This adjustment can help overcome minor obstructions in the IV line and facilitate better flow. However, it should be done cautiously to avoid excessive pressure on the IV site or causing discomfort to the client.
D. Opening the clamp fully for an extended period is not a recommended approach. It could lead to rapid infusion or an excessive flow rate, increasing the risk of complications such as fluid overload or vein irritation. Additionally, this action does not address the underlying reason for the slow flow rate and may not effectively resolve the issue.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

B. Tachycardia (elevated heart rate) can be a sign of various underlying conditions, including pain, anxiety, or cardiovascular compromise. While tachycardia may occur as a response to stress or pain associated with the catheter insertion procedure, it can also indicate complications such as hemorrhage, cardiac dysrhythmias, or pulmonary embolism, which require prompt evaluation and intervention.
A. While this can be concerning, it is not typically directly related to complications of a subclavian central venous catheter insertion unless there is evidence of arterial injury or thrombosis.
C. Bibasilar crackles are abnormal lung sounds that can indicate fluid accumulation in the lungs, such as pulmonary edema or pneumonia. However, this may not be directly related to the subclavian central venous catheter insertion itself.
D. Headache is a non-specific symptom that can have numerous causes, including stress, dehydration, or tension.

A. Stop the infusion immediately B. Document the findings in a nurse's note C. Flush the catheter with 3ml normal saline D. Remove the catheter and apply pressure to the site

Correct Answer is A

Explanation

A. Infiltration occurs when the intravenous solution leaks into the surrounding tissue instead of flowing into the vein. This can cause discomfort, swelling, and potential tissue damage. Stopping the infusion immediately helps prevent further infiltration and minimizes the risk of complications such as tissue necrosis or damage.
B. While documenting the findings is important for the client's medical record, it is not the first action to take when suspecting infiltration. Immediate intervention to stop the infusion and assess the site for complications takes precedence over documentation.
C. Flushing the catheter with normal saline may be necessary after stopping the infusion to ensure patency and clear any remaining solution from the catheter. However, this step should follow the immediate cessation of the infusion to prevent further infiltration.
D. Removing the catheter may be necessary if significant infiltration has occurred or if there are signs of tissue damage. However, this should be done after stopping the infusion to prevent further infiltration and should be based on the assessment findings and healthcare provider's instructions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The client's IV. placed near the right antecubital space, is running very slowly but does not appear infiltrated and does not have evidence of phlebitis. Which measure should the nurse implement to attempt to improve the flow rate of the IV?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who just had a subclavian central venous catheter inserted. Which symptom should the nurse recognize as setting a priority for this client's care?

Correct Answer is B

Explanation

The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?

Correct Answer is A

Explanation

The client's IV. placed near the right antecubital space, is running very slowly but does not appear infiltrated and does not have evidence of phlebitis. Which measure should the nurse implement to attempt to improve the flow rate of the IV?

The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment? (SELECT ALL THAT APPLY)

A client is admitted with a suspected opioid overdose and a respiratory rate of 6 breaths per minute. Which of the following data would the nurse anticipate? (SELECT ALL THAT APPLY)

The nurse understands that further teaching is needed when a client with narcolepsy states:

The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

What is the most important nursing intervention to increase sleep quality in the acute care hospital setting?

The nurse knows that an advantage of using a central venous access device is that:

A nurse is caring for a client in the dying process. How can the nurse best support the client and their family? (SELECT ALL THAT APPLY)