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 ["A","B","D","E"]

Explanation

Choice A reason: Obtaining a history of allergic reactions is crucial because the child will be exposed to various substances during cardiac catheterization, such as contrast dye, which could potentially cause an allergic reaction.
Choice B reason: Documenting lying, sitting, and standing blood pressures is important to assess for orthostatic hypotension, which could indicate volume depletion or cardiovascular problems that need to be addressed before the procedure.
Choice C reason: Performing a mini mental exam on the child is not typically part of the pre-procedure assessment for cardiac catheterization, especially given the young age of the child.
Choice D reason: Determining when the child last ate is essential because the child needs to have an empty stomach to reduce the risk of aspiration during sedation.
Choice E reason: Locating and marking the pedal pulses is important to establish baseline data so that post-procedure, any changes in the strength or presence of these pulses can be quickly identified, indicating potential complications.
Choice F reason: Measuring the child’s height and weight is generally part of a routine assessment but is not specifically focused on the pre-cardiac catheterization assessment unless dosing of medication or anesthesia is required based on weight.

A. Allow for menu deviations. B. Set precise mealtimes. C. Encourage exercise. D. Monitor trips to the restroom. E. Provide family education on the condition. F. Weigh the patient twice weekly. G. Acknowledge feelings of anxiety.

Correct Answer is ["A","B","D","E","F","G"]

Explanation

Choice A Reason: Allowing for menu deviations can help accommodate the patient’s preferences and encourage eating, which is crucial for recovery from emaciation.
Choice B Reason: Setting precise mealtimes can provide structure and consistency, which may help the patient establish regular eating habits.
Choice C Reason: Encouraging exercise is not appropriate at this stage due to the patient’s bradycardia and low BMI, which indicate a high risk for physical complications.
Choice D Reason: Monitoring trips to the restroom is important to prevent purging behaviors, which can be a concern in patients with eating disorders.
Choice E Reason: Providing family education on the condition is essential to ensure that the family understands the patient’s needs and how to support her recovery.
Choice F Reason: Weighing the patient twice weekly can help monitor her progress and adjust the treatment plan as needed.
Choice G Reason: Acknowledging feelings of anxiety is important for addressing the psychological aspects of the patient’s condition and promoting a supportive environment.

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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?

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