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 ["A","B","C"]

Explanation

A) A client who has had a cerebrovascular accident:
Clients who have had a cerebrovascular accident (stroke) often suffer from dysphagia (difficulty swallowing) due to impaired muscle control or sensory deficits. This makes them more susceptible to aspiration, as food or liquid can enter the airway instead of the esophagus.

B) A client who has had radiation therapy for head and neck cancer:
Radiation therapy in the head and neck area can cause damage to tissues, leading to mucositis, fibrosis, and reduced salivary flow, all of which can impair swallowing function. This increases the risk of aspiration because the normal mechanisms that protect the airway during swallowing may be compromised.

C) A client who is 4 hr postoperative following a leg amputation with general anesthesia:
General anesthesia can depress the gag and cough reflexes and impair coordination of the muscles involved in swallowing, making it more difficult for the client to protect their airway. This increased risk of aspiration is particularly relevant in the immediate postoperative period when the effects of anesthesia may still be present.

D) A client who has lactose intolerance:
Lactose intolerance primarily affects the digestive system and does not directly impact the mechanics of swallowing or increase the risk of aspiration. This condition leads to gastrointestinal symptoms such as bloating, diarrhea, and abdominal pain when consuming lactose-containing foods, but it does not increase the risk of food or liquid entering the airway during eating.

E) A client who has had prolonged diarrhea:
Prolonged diarrhea can lead to dehydration and electrolyte imbalances, but it does not directly affect the swallowing mechanism or increase the risk of aspiration. The primary concern with prolonged diarrhea is fluid and electrolyte management rather than an increased risk of aspiration during eating.

A. Helping the client select a low-salt diet B. Administering oxygen via nasal cannula at 2 Umin C. Encouraging the client to drink 2 to 3 L of water daily D. Maintaining a semi-Fowler's position as often as possible

Correct Answer is C

Explanation

A. Helping the client select a low-salt diet:
This option is not directly related to addressing tenacious bronchial secretions in COPD. While a low-salt diet may be beneficial for managing conditions like hypertension or heart failure, it does not directly influence the viscosity of bronchial secretions.

B. Administering oxygen via nasal cannula at 2 L/min:
Oxygen therapy is important for clients with COPD, especially during exacerbations or periods of hypoxemia. However, in this scenario, the client's primary concern is tenacious bronchial secretions, and oxygen therapy alone may not effectively address this issue.

C. Encouraging the client to drink 2 to 3 L of water daily:
This is the correct answer. Increasing fluid intake helps to hydrate the mucous membranes and thin bronchial secretions, making them easier to expectorate. Adequate hydration is essential for optimizing the clearance of secretions in clients with COPD.

D. Maintaining a semi-Fowler's position as often as possible:
While maintaining a semi-Fowler's position can improve respiratory mechanics and reduce dyspnea in clients with COPD, it does not directly address the issue of tenacious bronchial secretions. This position primarily helps in optimizing lung expansion and facilitating easier breathing.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (Select all that apply.)

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

Explanation

Correct Answer is C

Explanation

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