While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Apply ice then a warm compress to the IV site.

Discontinue the IV site after inserting a new access.

Redress the IV site while assessing for redness.

Review the medical record for the date of insertion.

Answer and Explanation

The Correct Answer is B

Rationale

A. Applying ice or a warm compress without assessing the site could potentially worsen any underlying issue.

B. The appropriate intervention would be to discontinue the IV site after ensuring a new access is established. This is because continuing to use a painful IV site can lead to complications such as infiltration or phlebitis.

C. Redressing the site without assessment does not address the client's complaint of pain.

D. Checking the medical record provides information about when the IV was inserted, which can be important for assessing the site's viability and expected duration. However, it doesn't address the immediate concern of the client's pain at the site or refusal of a flush.

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Correct Answer is B

Explanation

Rationale

A. Evacuation centers often accommodate a large number of people in close proximity. This can lead to increased transmission of infectious agents, including those causing diarrheal illnesses, through person- to-person contact or contaminated surfaces.

B. Hurricanes can cause flooding, which may overwhelm sewage systems and lead to contamination of drinking water sources. Consuming water contaminated by sewage can introduce pathogens that cause diarrheal diseases, such as bacteria like Escherichia coli or viruses like norovirus.

C. Flood waters can contaminate food supplies in various ways, such as direct contact with contaminated water, improper storage, or inadequate cooking or refrigeration. Consuming

contaminated food can result in diarrheal illnesses due to ingestion of pathogens like bacteria or parasites.

D. Nosocomial infections refer to infections acquired in healthcare settings. In a disaster medical area, improper infection control practices or overcrowding can contribute to nosocomial transmission of infectious agents, including those causing diarrheal diseases. However, this option is less likely in the context of a client seeking treatment for diarrhea immediately upon arrival at the disaster medical area.

A. Allow the client to take a position of comfort B. Discuss aggressive respiratory treatment options C. Prepare for deep tracheal suctioning D. Discuss with the client potential asthma triggers E. Wean the supplemental oxygen F. Obtain a sputum culture G. Monitor the oxygen saturation H. Consider positive pressure ventilation

Correct Answer is ["A","D","G"]

Explanation

A. Allowing the client to find a comfortable position can help reduce anxiety and promote relaxation, which can be beneficial during an asthma exacerbation.
B. While the patient is currently receiving treatment with albuterol and oxygen, discussing aggressive respiratory treatment options may not be necessary at this moment unless the patient's condition deteriorates and requires escalation of care.
C. Deep tracheal suctioning is not indicated based on the current assessment findings unless there is a specific clinical indication such as excessive secretions or respiratory distress.
D. Identifying and discussing potential triggers is important for asthma management. This helps the client understand what factors might exacerbate their asthma and how to avoid them in the future.
E. Since the patient's oxygen saturation is still below target (91% on room air), weaning the supplemental oxygen is not appropriate at this time. The oxygen therapy should be continued as per the titration orders to maintain saturation above 94%.
F. Obtaining a sputum culture is not typically indicated in acute asthma exacerbations unless there is suspicion of a secondary infection or if the patient develops persistent fever and productive cough.
G. Continuously monitoring oxygen saturation is crucial to ensure it remains above 94%. This helps gauge the effectiveness of treatment and ensures the patient's respiratory status is stable.
H. Positive pressure ventilation is a more advanced intervention and is not indicated based on the current assessment findings. It would only be considered if the patient's condition worsens despite maximal medical therapy.

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While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

Correct Answer is B

Explanation

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Correct Answer is ["A","D","G"]

Explanation

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