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. Iodinated contrast dye is commonly used in IVP procedures. Clients with a known allergy to iodine or shellfish may be at increased risk of an allergic reaction to the contrast dye. It is crucial to notify the healthcare provider so that appropriate pre-medication or alternative imaging options can be considered to minimize the risk of an allergic reaction.

B. While some procedures may require a urinary catheter, it is not routinely necessary for an IVP. Urinary catheters are generally used when precise urinary output measurement is required or when there are concerns about bladder function during and after the procedure. There is no specific indication for routine urinary catheterization before an IVP.

C. Drinking plenty of fluids before an IVP helps to ensure adequate hydration and can help flush the contrast dye from the body more quickly after the procedure. This can help reduce the risk of contrast dye-related complications such as nephrotoxicity and contrast-induced nephropathy.

D. After an IVP, there is no requirement for the client to keep their legs straight for an extended period. Typically, clients are observed for a brief period after the procedure to monitor for any immediate adverse reactions, but they are not required to keep their legs straight or remain immobile for an extended duration.

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?

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