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

Explanation

Choice A rationale

A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) is indicative of tuberculosis, an airborne disease. This client would require a room with negative airflow, use of a particulate respirator mask, and adherence to airborne as well as standard precautions.

Choice B rationale

Scabies is a skin infestation caused by a mite. It is transmitted through direct skin-to-skin contact and does not require airborne precautions.

Choice C rationale

Scarlet fever is a bacterial illness that often presents with a rash and is associated with strep throat. It is spread by direct contact with mucus, saliva, or skin sores of a person infected with the bacteria. It does not require airborne precautions.

Choice D rationale

Herpes simplex II lesions are typically sexually transmitted and do not require airborne precautions. Standard precautions would be sufficient.

A. Auscultate breath sounds. B. Measure the vital signs. C. Assist to a high Fowler’s position. D. Initiate deep breathing exercises.

Correct Answer is C

Explanation

Choice A rationale

While auscultating breath sounds is an important part of assessing a client’s respiratory status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

Choice B rationale

While measuring vital signs is an important part of assessing a client’s overall status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

Choice C rationale

Assisting the client to a high Fowler’s position can help alleviate dyspnea by allowing for greater lung expansion. This should be the nurse’s first action when a client with ascites is dyspneic.

Choice D rationale

While deep breathing exercises can help improve lung function and may be beneficial for a client with ascites, they are not the first action the nurse should take when the client is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

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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

The nurse is working on an infectious disease unit.Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is A

Explanation

The nurse observes that a client with ascites is dyspneic.Which action should the nurse implement first?

Correct Answer is C

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?