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 D

Explanation

Rationale

A. Wearing a face mask is a standard precaution to protect against airborne or droplet transmission of pathogens. However, MRSA is primarily transmitted through direct contact with infected wounds or contaminated surfaces rather than through the air.

B. Contact precautions are essential for preventing the spread of MRSA. These precautions include wearing gloves and gowns when in direct contact with the client or potentially contaminated surfaces. However, this is not of immediate concern.

C. Monitoring the white blood cell count (WBC) is crucial in assessing for signs of infection, including wound infections. An increase in WBC count can indicate systemic infection or local wound infection, which might be related to MRSA. Early detection and prompt reporting allow for timely intervention, such as initiating appropriate antibiotic therapy or further wound assessment.

D. This is because maintaining a clean environment around the wound is crucial to prevent infection

A. Obtain thickening powder before providing any more fluids. B. Assist the spouse and carefully give the client small sips of water. C. Ask the spouse to stop and assess the client's swallowing reflex. D. Give the spouse a straw to help facilitate the client's drinking.

Correct Answer is C

Explanation

Rationale

A. Thickening powder is used to modify the consistency of liquids to prevent aspiration in clients with swallowing difficulties. This option suggests ensuring safety by thickening fluids to reduce the risk of choking or aspiration. However, this does not address the underlying issue.

B. This option involves immediate action to provide hydration under close supervision. It implies that the nurse will closely monitor the client's ability to swallow and assess for signs of aspiration during the process. However, it does not address the underlying risk.

C. This option focuses on assessing the client's ability to swallow before providing more fluids. It acknowledges the potential danger of giving fluids without knowing the client's current swallowing ability, which could lead to aspiration.

D. Providing a straw might seem helpful but could potentially increase the risk of aspiration if the client has swallowing difficulties. It does not address the immediate need for assessing the client's ability to swallow safely.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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