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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E","H"]
Explanation
H.
Choice A rationale
While albuterol can cause an increase in heart rate due to its beta-agonist effects, it is not the primary assessment following administration. The main goal of albuterol treatment is to improve respiratory function.
Choice B rationale
Breath sounds are a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve breath sounds by reducing bronchospasm and increasing airflow.
Choice C rationale
Serum sodium levels are not directly affected by albuterol and therefore are not a primary assessment following its administration.
Choice D rationale
A complete blood count is not directly affected by albuterol and therefore is not a primary assessment following its administration.
Choice E rationale
Oxygen saturation is a primary assessment following albuterol administration. Albuterol should improve oxygen saturation by increasing airflow and oxygen delivery.
Choice F rationale
Peak inspiratory flow is not typically assessed after albuterol administration. Albuterol primarily affects expiratory flow by reducing bronchospasm.
Choice G rationale
Temperature is not directly affected by albuterol and therefore is not a primary assessment following its administration.
Choice H rationale
Peak expiratory flow is a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve peak expiratory flow by reducing bronchospasm.
Correct Answer is B
Explanation
Choice A rationale
Noting the presence of an auscultatory gap, which is a period of abnormal silence in Korotkoff sounds during blood pressure measurement, is important. However, in this case, the silence followed by a Korotkoff sound is a normal finding and does not indicate an auscultatory gap.
Choice B rationale
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. This is a normal finding and indicates that the nurse should continue with the blood pressure assessment.
Choice C rationale
Re-inflating the cuff to a higher number is not necessary in this case as the initial silence followed by a Korotkoff sound is a normal finding.
Choice D rationale
Repositioning the stethoscope over the brachial artery may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.
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