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 A

Explanation

Rationale

A. The client's pH is low (acidotic), and the PaCO2 is high (respiratory acidosis). Increasing the rate of ventilation (respiratory rate) can help to decrease PaCO2 by increasing alveolar ventilation, thereby helping to correct respiratory acidosis.

B. Expiratory flow time affects the time available for exhalation. While this may affect the overall mechanics of ventilation, it is not directly targeting the primary issue of elevated PaCO2 and acidosis.

C. Increasing tidal volume increases the volume of air delivered with each breath. This can improve ventilation efficiency but may not address the underlying problem of elevated PaCO2 unless it leads to increased minute ventilation.

D. Expiratory pressure is related to positive end-expiratory pressure (PEEP), which helps maintain alveolar recruitment and improve oxygenation. Decreasing expiratory pressure may not directly address the elevated PaCO2 and acidosis.

A. Neutrophil count. B. Hematocrit. C. Platelet count. D. Serum sodium level.

Correct Answer is A

Explanation

Rationale

A. An elevated neutrophil count suggests an active immune response to infection, supporting the clinical findings of purulent drainage. This information is crucial for the healthcare provider to assess the severity of the infection and guide treatment.

B. Hematocrit changes are more related to blood volume, fluid shifts, or bleeding rather than infection. While it may be monitored postoperatively, it does not provide specific information about infection.

C. Platelet count is important for assessing clotting function but does not directly indicate infection or purulent drainage.

D. Serum sodium levels are part of electrolyte balance and hydration status monitoring but do not directly relate to the presence of infection.

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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

Correct Answer is A

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is A

Explanation

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