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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Free Nursing Study Resources

Correct Answer is ["0.75"]

Explanation

Calculate the volume of the reconstituted solution that contains the prescribed dose of 0.1875 mg. Since the reconstituted solution has a concentration of 0.25 mg per 1 mL, we can set up a proportion to find the answer: (0.1875 mg / X mL) = (0.25 mg / 1 mL).

Solving for X gives us X = (0.1875 mg * 1 mL) / 0.25 mg, which equals 0.75 mL.

Therefore, the nurse should administer 0.75 mL of the reconstituted solution.

Correct Answer is "{\"xRanges\":[389.5,439.5],\"yRanges\":[222,272]}"

Explanation

Site- the nose

Rationale

Rhinorrhea refers specifically to cerebrospinal fluid (CSF) rhinorrhea. This occurs when there is a leakage of CSF from the nose due to a fracture or injury to the skull base or surrounding structures, such as the cribriform plate.

CSF is a clear fluid that surrounds and cushions the brain and spinal cord. When there is a fracture or disruption in the skull base, CSF can leak out through the nasal passages. This condition is concerning because it can increase the risk of infection, such as meningitis, due to the direct communication between the central nervous system and the external environment through the nasal cavity.

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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 ["0.75"]

Explanation

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

Correct Answer is "{\"xRanges\":[389.5,439.5],\"yRanges\":[222,272]}"

Explanation

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