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While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.
What should the nurse do next?

A.

Apply ice, then a warm compress to the IV site.

B.

Check the medical record for the date of IV insertion.

C.

Redress the IV site while checking for redness.

D.

Discontinue the current IV site and insert a new one.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Applying ice, then a warm compress to the IV site may help with pain or inflammation, but it does not address the potential problem with the IV site itself. If the client is experiencing pain and refuses a flush to assess the site, it could indicate that the IV site is compromised.

Choice B rationale

Checking the medical record for the date of IV insertion could provide useful information about how long the IV has been in place, but it does not directly address the client’s current complaint of pain at the IV site.

Choice C rationale

Redressing the IV site while checking for redness could help identify signs of infection or inflammation, but it does not address the client’s complaint of pain or their refusal to have the site flushed.

Choice D rationale

Discontinuing the current IV site and inserting a new one is the most appropriate action in this situation. If the client is experiencing pain at the IV site and refuses a flush to assess the site, it suggests that the current IV site may be compromised. Inserting a new IV ensures that the client can continue to receive their scheduled IV medication safely.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"}}

Explanation

Based on the questionand the known effects of furosemide, here’s how each assessment finding can be categorized:

  • Potassium 3.1 mEq/L: This is anon-therapeutic side effect.Furosemide is a diuretic that increases the excretion of water, sodium, and potassium from the body.This can lead to hypokalemia, or low potassium levels.
  • Prothrombin time/INR 2.2: This is likely anunrelated finding.Furosemide does not typically affect prothrombin time or INR.However, the patient is also taking warfarin, which is an anticoagulant known to increase INR.
  • Urine output: 600 mL: This is atherapeutic result.Furosemide works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention.

Correct Answer is D

Explanation

Choice A rationale

Printing the electronic medical record (EMR) from the backup server may not be the most immediate action required. While having a backup of the EMR is important, it does not address the immediate issue of the system failure.

Choice B rationale

Waiting for notification that the system has been rebooted is a passive approach and may not be the most effective initial action. It does not address the immediate need to communicate the issue to the appropriate department.

Choice C rationale

Identifying information as a late entry in the record is a documentation practice that is used when charting is not completed in a timely manner. However, this action does not address the immediate issue of the system failure.

Choice D rationale

Notifying the information services department of the situation is the correct action. This allows the appropriate department to begin troubleshooting and resolving the issue. In the event of a system failure, the first step should be to report the issue so that it can be addressed as quickly as possible.

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