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?

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

Check the medical record for the date of IV insertion.

Redress the IV site while checking for redness.

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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Correct Answer is ["A","B","C","D","E","F"]

Explanation

Based on the client’s history and physical, the following areas increase the risk for postpartum hemorrhage:

Gravida 5 Para 5 (G5P5): Multiparity (having given birth 5 times) can increase the risk of postpartum hemorrhage due to uterine atony (lack of muscle tone) resulting from repeated stretching of the uterus.
Delivery of a 9 lb 1 oz (4.1 kg) baby: Macrosomia (large baby) can overstretch the uterus, increasing the risk of uterine atony and postpartum hemorrhage.
Labor for 25 hours and use of forceps for delivery: Prolonged labor and instrumental delivery can lead to uterine fatigue and atony, increasing the risk of postpartum hemorrhage.
4th degree laceration: Severe lacerations can lead to significant blood loss.
Estimated blood loss was 600 mL after delivery: This is a significant amount of blood loss and could indicate a risk for further hemorrhage.
Lochia rubra moderate with small clots: This could indicate ongoing blood loss.

A. Production of extra platelets. B. Depletion of clotting factors. C. Inhibition of red blood cell production. D. Activation of complement pathways.

Correct Answer is B

Explanation

Choice A rationale

Production of extra platelets is not the primary pathophysiological process in Disseminated Intravascular Coagulation (DIC). While the body may try to produce more platelets in response to the widespread clotting, this is not the cause of the coagulation problem.

Choice B rationale

Depletion of clotting factors is a key feature of DIC. In the initial phase of DIC, there is an overactive clotting process leading to the formation of small blood clots throughout the body’s blood vessels. This overactive clotting uses up platelets and clotting factors, leading to a state where the body is unable to control bleeding, which is the second phase of DIC34.

Choice C rationale

Inhibition of red blood cell production is not a primary feature of DIC. While DIC can lead to anemia due to blood loss from excessive bleeding, it does not directly inhibit the production of red blood cells.

Choice D rationale

Activation of complement pathways is part of the body’s immune response and is not the primary cause of the coagulation problem in DIC34.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A patient with septic shock develops Disseminated Intravascular Coagulation (DIC). Which pathophysiological process should the nurse identify as the cause of the coagulation problem?

Correct Answer is B

Explanation

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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?

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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?