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 C

Explanation

Rationale

A. During a thoracentesis, a needle is inserted through the chest wall into the pleural space to remove fluid or air. It's common for clients to feel a stinging sensation or discomfort during needle insertion. The nurse should confirm this understanding with the client and reassure them that local anesthesia will be used to minimize discomfort.

B. The positioning described (sitting forward with arms propped on a table) helps to expand the intercostal spaces and facilitates easier access to the pleural space during the procedure. The nurse should reinforce this position as appropriate for the thoracentesis procedure.

C. This statement is incorrect and would indicate a need for additional education. A persistent cough is not an expected outcome after a thoracentesis. While some clients may experience a mild cough during or immediately after the procedure due to irritation from the needle or local anesthesia, it should not persist afterwards.

D. This statement is generally correct. After a thoracentesis, it is recommended to limit strenuous activity and avoid heavy lifting for a day or two to minimize the risk of complications such as discomfort or injury at the needle insertion site. The nurse should support this instruction as part of the client's post-procedure care.

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

Correct Answer is B

Explanation

Rationale

A. Measuring vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, is important to assess the client's overall status and to determine the severity of the dyspnea. Vital signs provide essential information to guide further interventions. While important, this action may not directly alleviate the client's immediate distress from dyspnea.

B. Placing the client in a high Fowler's position (sitting upright with the head of the bed elevated to 90 degrees) helps to maximize chest expansion and improve lung ventilation. This position can relieve dyspnea by reducing pressure on the diaphragm and improving lung compliance. It is a simple and effective intervention for clients experiencing respiratory distress.

C. While deep breathing exercises are beneficial for promoting lung expansion and improving respiratory function, they may not be appropriate as the first action when the client is already dyspneic. The priority

should be to position the client to alleviate immediate breathing difficulty before initiating exercises that require active participation.

D. Auscultating breath sounds is important for assessing lung function and detecting any abnormalities such as adventitious sounds (e.g., crackles, wheezes). However, this action is secondary to placing the client in a high Fowler's position to relieve dyspnea. Auscultation can be performed after the client's breathing has stabilized.

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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

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Correct Answer is C

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Explanation

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