A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Administer an analgesic PO.

Request a prescription for placement of a central venous access device.

Administer a local anesthetic.

Remove the catheter and insert another into a different site.

Answer and Explanation

The Correct Answer is D

A.   Administering an analgesic by mouth (PO) may not provide immediate relief for the pain at the insertion site. It is more effective to address the issue directly by repositioning the IV catheter.
B.   Requesting a prescription for a central venous access device is not necessary in this situation. If peripheral IV access is indicated, the nurse should aim to find a suitable site for insertion.
C.   Administering a local anesthetic may not be necessary if the pain is solely related to the insertion of the IV catheter. Repositioning the catheter to a more comfortable site is a more appropriate first step.
D.   If the client reports pain at the insertion site after the IV catheter has been placed, it may indicate that the catheter is not properly positioned or may be causing discomfort. In this case, it is appropriate for the nurse to remove the catheter and select a different site for insertion.

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Correct Answer is B

Explanation

A. The reported tympanic temperature of 37.1°C (98.8°F) is within normal range.
B. The blood pressure (BP) reading of 98/58 mm Hg indicates a relatively low diastolic pressure. Diastolic pressure is an important indicator of perfusion to vital organs, especially the coronary arteries and the brain. It's crucial to ensure that this reading is accurate.
C. The reported pulse rate of 92/min falls within the normal range for an adult at rest.
D. The reported respiratory rate of 18/min is within the normal range for an adult at rest.

A. Potassium level B. Prealbumin level C. History of diabetes mellitus D. History of hyperlipidemia E. Wound infection F. Decreased pedal perfusion G. Fasting blood glucose

Correct Answer is ["B","C","D","E","F"]

Explanation

A. Potassium level is incorrect because it is within the normal range and does not affect wound healing directly.
B. Prealbumin level is correct because it is low, indicating malnutrition and poor protein intake, which are essential for tissue repair and immune function.
C. History of diabetes mellitus is correct because it causes impaired blood flow, increased risk of infection, and delayed inflammatory response, which all hinder wound healing.
D. History of hyperlipidemia is correct because it causes atherosclerosis and reduced blood supply to the affected area, which limits oxygen and nutrient delivery to the wound.
E. Wound infection is correct because it increases inflammation, tissue damage, and metabolic demands, which prolong the healing process and may lead to complications.
F. Decreased pedal perfusion is correct because it indicates poor circulation to the lower extremities, which impairs wound healing by reducing oxygen and nutrient delivery to
the wound.
G. Fasting blood glucose is incorrect because it is not a direct cause of delayed wound healing, but rather a reflection of the client's diabetes management. However, high blood glucose levels can impair wound healing by affecting blood flow, immune function, and collagen synthesis.

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A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Correct Answer is B

Explanation

Correct Answer is ["B","C","D","E","F"]

Explanation

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