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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Discussing symptomless partners may give false reassurance, as herpes can be transmitted even when symptoms are not present.

Choice B reason: Notifying sexual partners is crucial for public health and the prevention of further transmission of STIs.

Choice C reason: While it's true that STIs are reported, this does not provide the client with actionable advice for their situation.

Choice D reason: Most contraceptives do not protect against STIs like genital herpes, which is spread by skin-to-skin contact.

A. Avoid prolonged standing or sitting. B. Cross legs at the knee but not at the ankle. C. Continue wearing compression stockings. D. Use a recliner for long periods of sitting. E. Maintain the bed flat while sleeping.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is: a, c, d.

Choice A: Avoid prolonged standing or sitting

Reason: Prolonged standing or sitting can exacerbate symptoms of chronic venous insufficiency (CVI) by increasing venous pressure and promoting blood pooling in the legs. Movement helps to enhance venous return and reduce swelling.

Choice B: Cross legs at the knee but not at the ankle

Reason: Crossing legs at the knee can impede blood flow and increase venous pressure, which is counterproductive for managing CVI. It is generally advised to avoid crossing legs at the knee to promote better circulation.

Choice C: Continue wearing compression stockings

Reason: Compression stockings are a cornerstone in the management of CVI. They help to improve venous return, reduce swelling, and prevent blood from pooling in the legs. Compression stockings should be worn as prescribed, typically during the day and removed at night.

Choice D: Use a recliner for long periods of sitting

Reason: Using a recliner can help elevate the legs above heart level, which reduces venous pressure and promotes venous return. This position can help alleviate symptoms of CVI.

Choice E: Maintain the bed flat while sleeping

Reason: Maintaining the bed flat while sleeping is not recommended for CVI management. Elevating the legs while sleeping can help reduce venous pressure and prevent blood from pooling in the legs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Correct Answer is B

Explanation

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

Choice A: Avoid prolonged standing or sitting

Choice B: Cross legs at the knee but not at the ankle

Choice C: Continue wearing compression stockings

Choice D: Use a recliner for long periods of sitting

Choice E: Maintain the bed flat while sleeping

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