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 C

Explanation

Choice A rationale

Discussing moving to Hawaii does not necessarily indicate a connection to the client’s current condition. It could be a long-term plan or a dream.

Choice B rationale

Being unemotional when talking about needing to rebuild their house could indicate a coping mechanism or emotional detachment. However, without additional context, it’s difficult to definitively associate this behavior with their current condition.

Choice C rationale

Expressing a desire to be in a quieter area of the unit could indicate that the client is experiencing stress, anxiety, or discomfort in their current environment. This behavior is most likely associated with their current condition as it shows a direct response to their surroundings.

Choice D rationale

Requesting sleeping medication for the night could indicate various issues such as insomnia, anxiety, or other sleep-related disorders. However, without more information about the client’s current condition, it’s not possible to make a direct association.

A. Walking at least once an hour at work. B. Increasing exercise intensity. C. Avoiding foods with high carbohydrate levels. D. Selecting foods that are lower in caloric density.

Correct Answer is D

Explanation

Choice A rationale

Walking at least once an hour at work can be beneficial for overall health and can contribute to maintaining energy balance. However, it may not be the most effective action for maintaining energy balance for a person who already exercises 2 to 3 times per week.

Choice B rationale

Increasing exercise intensity can help burn more calories and can contribute to maintaining energy balance. However, it’s important to note that exercise alone may not be sufficient for maintaining energy balance if not combined with a balanced diet.

Choice C rationale

Avoiding foods with high carbohydrate levels is not necessarily an effective action for maintaining energy balance. Carbohydrates are a primary source of energy for the body. While it’s important to choose complex carbohydrates over simple ones, avoiding carbohydrates altogether is not recommended.

Choice D rationale

Selecting foods that are lower in caloric density is an effective action for maintaining energy balance. Foods that are lower in caloric density, such as fruits and vegetables, can provide essential nutrients without contributing excessive calories. This can help maintain energy balance and prevent weight gain.

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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

Which client statement or behavior is most likely associated with their current condition?

Correct Answer is C

Explanation

A 33-year-old female client, who denies smoking, drinking, or using any illicit drugs, exercises 2 to 3 times per week and has an office job.She weighs 68 kg and is 156 cm tall.Which of the following actions would be effective in maintaining her energy balance?

Correct Answer is D

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?