A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take?

Apply a warm compress to the IV site.

Remove the IV saline lock.

Inject the solution more slowly while flushing the IV saline lock.

Apply firm pressure to the plunger of the syringe during the NV flush to improve patency.

Answer and Explanation

The Correct Answer is B

A. Apply a warm compress to the IV site: While warm compresses can sometimes help alleviate discomfort associated with certain IV complications, such as phlebitis or infiltration, they should not be applied until the cause of the pain is identified. In this case, removing the IV saline lock is the priority action to assess the site properly.

B. Remove the IV saline lock: Pain above the catheter site during flushing may indicate infiltration or phlebitis, both of which require intervention. Removing the IV saline lock allows the nurse to assess the site for signs of complications such as swelling, redness, or coolness to the touch. Once removed, the nurse can then determine the appropriate course of action, such as reinserting the IV at a different site, applying warm compresses, or notifying the healthcare provider if further evaluation or treatment is necessary.

C. Inject the solution more slowly while flushing the IV saline lock: Injecting the solution more slowly may reduce discomfort during flushing, but it does not address the underlying cause of the pain. If there is infiltration or another issue with the IV site, continuing to flush slowly could exacerbate the problem.

D. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency: Applying firm pressure to the plunger of the syringe during flushing is not appropriate when the client reports pain above the catheter site. This action could potentially force fluid into surrounding tissues, worsening infiltration or causing additional discomfort. It is essential to address the pain and assess the IV site before attempting to flush the saline lock again.

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Correct Answer is D

Explanation

A. Increased blood pressure:
In hypovolemia, the body experiences a significant loss of blood volume, which leads to a reduction in the amount of blood available to circulate through the vessels. This causes a drop in blood pressure, known as hypotension, rather than an increase. The body tries to compensate for the lower blood volume by constricting blood vessels and increasing heart rate, but this typically isn't sufficient to increase blood pressure to normal levels.

B. Decreased heart rate:
The body's natural response to hypovolemia includes an increase in heart rate, known as tachycardia, as the heart attempts to pump the remaining blood more efficiently to vital organs. This compensatory mechanism aims to maintain cardiac output despite the decreased blood volume.

C. Dyspnea:
Dyspnea, or difficulty breathing, can occur in many medical conditions, including heart failure and respiratory issues. While it can be seen in severe cases of hypovolemia, particularly if the condition leads to shock and subsequent multi-organ failure, it is not a primary or specific sign of hypovolemia.

D. Weak pulse:
A weak pulse is a primary and direct manifestation of hypovolemia. Due to the reduced volume of circulating blood, the heart has less blood to pump with each contraction, leading to a weaker pulse. This symptom indicates a decreased perfusion pressure, which is characteristic of hypovolemia. The body's compensatory mechanisms include vasoconstriction and an increased heart rate, but these measures often result in a pulse that is rapid but weak.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}

Explanation

Potassium Levels: The postoperative potassium level for the client is 3.0 mEq/L, which falls below the normal range of 3.5 to 5 mEq/L. Potassium is a critical electrolyte necessary for the proper functioning of cardiac muscles. It plays a pivotal role in maintaining the electrical conductivity of the heart. Hypokalemia, or low potassium levels, can disrupt this electrical conductivity, leading to abnormal heart rhythms or arrhythmias. Arrhythmias can manifest as palpitations, irregular heartbeats, or more severe cardiac events, which can be life-threatening if not addressed promptly.

Importance of Potassium in Cardiac Function: Potassium is essential for the repolarization phase of the cardiac action potential. It helps in the return of the cell to its resting state after each heartbeat. A deficiency in potassium disrupts this balance, increasing the risk of erratic heartbeats and arrhythmias. Low potassium can prolong the QT interval on an electrocardiogram (ECG), which is a marker for potential arrhythmic events.

Clinical Implications: For a postoperative client, maintaining electrolyte balance is crucial. Surgery and anesthesia can affect fluid and electrolyte levels, making it essential to monitor and correct any imbalances. The decrease in potassium levels from 3.5 mEq/L preoperatively to 3.0 mEq/L postoperatively highlights a trend that must be addressed to prevent complications such as arrhythmias.

Preventative Measures: To mitigate the risk of arrhythmias, the healthcare team should consider interventions to correct the hypokalemia. This may include administering potassium supplements orally or intravenously, depending on the severity and clinical context. Continuous cardiac monitoring may also be warranted to detect and manage any emerging arrhythmic events promptly.

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