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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. Localized edema:
Localized edema, especially when accompanied by erythema (redness), warmth, and tenderness, can be indicative of an infection in a client with diabetes mellitus. Infections in diabetic patients, particularly those affecting the feet, can lead to localized inflammation and swelling.
B. An increase in RBCs:
An increase in red blood cells (RBCs), known as erythrocytosis, is not typically associated with an infection. Erythrocytosis may occur in conditions such as polycythemia vera or chronic hypoxemia but is not a typical marker of infection.
C. Bradycardia:
Bradycardia, a heart rate slower than the normal range, is not typically associated with infections. Infections often cause tachycardia (an increased heart rate) as part of the body's systemic inflammatory response.
D. An increase in platelets:
An increase in platelets, known as thrombocytosis, is not typically associated with infections. Thrombocytosis can occur in response to various factors, including inflammation, but it is not a specific marker of infection in diabetic clients with foot pain.
E. An increase in neutrophils:
An increase in neutrophils, known as neutrophilia, is a common response to infection. Neutrophils are a type of white blood cell involved in the body's immune response to bacterial infections. In diabetic clients with foot pain, an elevated neutrophil count may suggest the presence of an infection, as the body mobilizes these cells to combat the invading pathogens.
Correct Answer is A
Explanation
A. Cancer pain: Cancer pain can result from tumor growth, tissue invasion, or nerve compression caused by cancer. It can be acute or chronic and may vary in intensity. However, in this scenario, the client's pain is specifically associated with dermatitis resulting from radiation therapy, rather than directly from the cancer itself.
B. Acute pain: Acute pain is typically sudden in onset and is often associated with tissue injury or damage. In this case, the painful dermatitis resulting from radiation therapy would be considered acute pain because it is directly related to the recent tissue damage caused by the radiation. Acute pain is usually short-term and resolves as the underlying cause heals or is treated.
C. Chronic pain: Chronic pain persists beyond the expected time for tissue healing and is often associated with conditions such as arthritis or neuropathy. While cancer pain can sometimes become chronic if it persists over time, the pain described in this scenario is more likely to be acute given its association with recent radiation therapy.
D. Neuropathic pain: Neuropathic pain results from damage or dysfunction of the nervous system and can present as shooting or burning sensations. While neuropathic pain can occur in cancer patients, the pain described in this scenario is more likely to be acute and related to tissue damage from radiation therapy rather than neuropathy.
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