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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Correct choices are;
A.I should have taken an extra dose of fluticasone-salmeterol -No Understanding
Explanation: Fluticasone/salmeterol is a long-acting inhaler used for maintenance therapy in asthma. It is not meant to be used as a rescue medication for acute symptoms or exacerbations. Therefore, taking an extra dose in response to symptoms would not be appropriate.
B. I should have taken some allergy medications before going on the hike -Understanding
Explanation: Allergy medications, such as antihistamines or nasal sprays, can help reduce allergic triggers that can exacerbate asthma symptoms. Taking these medications before exposure to known triggers (like allergens during a hike) can help prevent an asthma exacerbation.
C. I have been very stressed out lately and should work on stress management -Understanding
Explanation: Stress is a known trigger for asthma exacerbations. Managing stress through techniques such as relaxation exercises, mindfulness, or therapy can help reduce the likelihood of triggering asthma symptoms.
D. I should have eaten a snack halfway through the hike - No Understanding
Explanation: While maintaining good nutrition and hydration is important for overall health, eating a snack would not necessarily prevent an asthma exacerbation unless the snack contained medications or substances that specifically manage asthma symptoms.
E. My friend smoked cigarettes during the hike - Understanding
Explanation: Secondhand smoke is a common trigger for asthma exacerbations. Being exposed to cigarette smoke can irritate the airways and worsen asthma symptoms.
Correct Answer is B
Explanation
Rationale
A. Respiratory rate is important because opioid-induced respiratory depression is a significant concern with hydromorphone. Assessing the respiratory rate helps the nurse detect early signs of respiratory depression.
B. Pain scale is essential to evaluate the effectiveness of the equianalgesic dose. The nurse should ensure that the pain is adequately controlled with the IV dose comparable to what was achieved with the PO dose.
C. Blood pressure is monitored to detect any potential hypotensive effects of hydromorphone, particularly with IV administration.
D. Level of consciousness is assessed to ensure that the client is not overly sedated or experiencing other neurological side effects of the medication.
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