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 C

Explanation

A. The nurse is not responsible for obtaining informed consent. This is the responsibility of the healthcare provider performing the procedure, who must explain the risks, benefits, and alternatives to the client. The nurse may assist in ensuring the client has the necessary information, but the final responsibility for obtaining consent lies with the provider.

B. Explaining the risks and benefits of the procedure is part of the informed consent process.
The client needs to be informed about potential risks, benefits, and alternatives before giving consent.

C. This is correct. The nurse's role in the informed consent process is to witness the client's signature after the healthcare provider has explained the procedure, risks, and benefits. The nurse verifies that the client is signing voluntarily and understands the consent form, but the nurse does not provide the explanation.

D. Explaining the procedure to the client if they do not understand is essential for ensuring that the client has sufficient information to make an informed decision. This should be done in a clear and understandable manner.

A. Lactated Ringer's B. 0.45% sodium chloride C. Dextrose 5% in 0.9% sodium chloride D. Dextrose 10% in water

Correct Answer is B

Explanation

A. Lactated Ringer's is a balanced electrolyte solution, but it contains sodium in a similar concentration to normal serum levels. It is not appropriate for a client with hypernatremia, as it could further increase their sodium levels.
B. 0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
C. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.
D. Dextrose 10% in water is a hypertonic solution with a high concentration of dextrose.
It does not contain sodium, but it is still a hypertonic solution and not appropriate for a client with hypernatremia.

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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

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Explanation

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Correct Answer is B

Explanation

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