While the nurse is preparing a scheduled IV medication, the client states 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?
Review the medical record for the date of insertion.
Apply ice first, then a warm compress to the IV site.
Document that the medication was not administered.
Discontinue the painful IV after a new IV is inserted.
The Correct Answer is D
Choice A reason: Reviewing the medical record for the date of insertion is important but does not address the immediate concern of pain or potential complications at the IV site.
Choice B reason: Applying ice and then a warm compress may be used for phlebitis or infiltration, but if the client is experiencing pain, the priority is to address the potential for complications.
Choice C reason: Documentation is a necessary step, but it should not be the first action taken when a client reports pain at the IV site.
Choice D reason: If the IV site is painful, it may be indicative of infiltration, phlebitis, or another complication. The nurse should discontinue the painful IV and insert a new one at a different site to prevent further discomfort and potential harm to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.
Choice B reason: While recommending a complete bath may help maintain hygiene, it does not directly address the immediate need to stimulate voiding. The nurse's priority is to manage the incontinence issue effectively and a bath can be considered after addressing the client's immediate needs.
Choice C reason: Suggesting catheter insertion may be premature without first attempting less invasive measures. Catheterization carries risks such as infection and should be considered only when other interventions are ineffective or not feasible.
Choice D reason: There is no evidence to suggest that pouring warm water over the perineal area promotes infection in elderly females. In fact, proper perineal care is essential in preventing infections, especially in clients with incontinence.
Correct Answer is ["A","D","E","F","H"]
Explanation
Choice A reason: Applying sequential compression stockings when in bed is a recommended postoperative intervention for bariatric surgery patients. It helps prevent deep vein thrombosis (DVT) by promoting venous return and reducing venous stasis, which is particularly important in patients with obesity due to their increased risk for DVT.
Choice B reason: Maintaining strict bedrest for 12 hours after surgery is not typically recommended as it can increase the risk of complications such as DVT and pulmonary embolism. Early mobilization is generally encouraged to promote circulation and respiratory function.
Choice C reason: Providing chilled beverages is not a specific nursing intervention indicated in the immediate postoperative period for bariatric surgery patients. Fluid intake should be carefully monitored and regulated, but the temperature of the beverages is not a primary concern.
Choice D reason: Changing position frequently is an important postoperative intervention to prevent complications such as pressure ulcers and to promote lung expansion, especially in patients with obesity who are at higher risk for these issues.
Choice E reason: Encouraging coughing and deep breathing is essential after bariatric surgery to help clear the airways, prevent atelectasis, and improve oxygenation. This is particularly important for this patient who has a history of sleep apnea and reported diminished breath sounds postoperatively.
Choice F reason: Observing for signs and symptoms of dumping syndrome is relevant for bariatric surgery patients, as this syndrome can occur when food moves too quickly from the stomach to the small intestine. However, this is more of a long-term concern rather than an immediate postoperative intervention.
Choice G reason: Keeping the client NPO (nothing by mouth) is a common immediate postoperative order, but as the patient progresses, they will be started on a liquid diet and advanced as tolerated. Therefore, it is not a nursing intervention that would be indicated indefinitely.
Choice H reason: Maintaining the head at a 45-degree angle can help improve respiratory function by reducing pressure on the diaphragm, which is especially beneficial for patients with obesity and a history of sleep apnea, as in this case.
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