Following three days of nausea, vomiting, and diarrhea, an older adult is admitted with severe dehydration. After two attempts, the nurse secured venous access using a 24-gauge IV catheter and began infusing 0.9% normal saline at 150 mL/hour. Minutes later, the client reports pain at the IV site. Which intervention should the nurse implement first?

Assess the IV site for blood return.

Stop the 0.9% normal saline infusion.

Establish IV access in a different extremity.

Select a different gauge IV needle.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing blood return checks patency, but pain suggests infiltration or phlebitis, where saline leaks into tissues. Stopping the infusion prevents further tissue damage, as extravasation causes swelling or necrosis, especially in dehydrated elderly clients, making assessment secondary to halting infusion.

Choice B reason: Stopping the saline infusion is the priority, as pain at the IV site suggests infiltration or phlebitis, with fluid irritating tissues or veins. Halting infusion prevents damage, allowing safe assessment and management, critical in fragile elderly veins, ensuring no further harm during rehydration.

Choice C reason: Establishing new IV access is necessary post-infiltration but not first. Pain indicates ongoing tissue irritation from saline leakage, requiring immediate infusion cessation to prevent damage. Stopping the infusion ensures safety before reattempting access, critical in dehydrated patients needing fluid replacement.

Choice D reason: Selecting a different gauge needle is irrelevant, as the 24-gauge catheter is placed, and pain indicates infiltration, not size. Stopping the infusion prevents extravasation, which risks compartment syndrome in elderly clients, making this less immediate than halting the infusion for safety.

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Correct Answer is A

Explanation

Choice A reason: Crackles in bilateral lower lobes indicate pulmonary edema in heart failure, where reduced cardiac output causes fluid backup into alveoli, impairing gas exchange and causing dyspnea. This life-threatening emergency requires immediate diuretics or oxygen to reduce preload, preventing respiratory failure or hypoxia, prioritizing intervention.

Choice B reason: A heart rate of 92 beats/minute is normal and not urgent in heart failure, where dyspnea and fatigue suggest fluid overload. Crackles indicate pulmonary edema, a critical issue compromising oxygenation, necessitating immediate action to restore respiratory function, making heart rate less concerning.

Choice C reason: Blood pressure of 138/86 mm Hg is mildly elevated but not critical in heart failure. Crackles signal pulmonary edema, where fluid in alveoli impairs gas exchange, risking hypoxia. This requires urgent intervention like furosemide, as respiratory compromise is more immediate than managing stable blood pressure.

Choice D reason: Peripheral edema 1+ indicates fluid retention in heart failure but is less urgent than crackles, which signify pulmonary edema. Alveolar fluid causes dyspnea and hypoxia, requiring immediate diuretics. Edema is chronic, making respiratory assessment and intervention the priority to prevent acute respiratory failure.

A. Enroll in a smoking cessation program. B. Reduce intake of high saturated fats and salt. C. Keep toenails trimmed short. D. Apply heating pad to soothe leg pain.

Correct Answer is A

Explanation

Choice A reason: Smoking exacerbates PAD via nicotine-induced vasoconstriction and endothelial damage, reducing blood flow and worsening atherosclerosis, especially post-MI. Cessation is critical to halt vascular damage, improve endothelial function, and prevent further MI or limb ischemia, addressing the primary pathophysiological driver of disease progression in this high-risk client.

Choice B reason: Reducing saturated fats and salt lowers LDL cholesterol and blood pressure, mitigating atherosclerosis in PAD and MI. However, smoking directly causes vasoconstriction and plaque progression, making cessation more urgent. Dietary changes are secondary, as nicotine’s immediate vascular effects pose a greater risk to perfusion and cardiovascular health.

Choice C reason: Trimming toenails short prevents injury in PAD, where poor perfusion impairs healing. However, smoking cessation is more critical, as nicotine’s vasoconstrictive effects directly reduce arterial flow, worsening ischemia. Nail care is a minor preventive measure compared to addressing smoking, the primary contributor to PAD’s pathophysiology.

Choice D reason: Applying a heating pad is contraindicated in PAD, as reduced sensation increases burn risk, and heat doesn’t improve arterial insufficiency. Smoking cessation is paramount, as nicotine exacerbates vasoconstriction, reducing blood flow and risking tissue necrosis. Cessation directly addresses PAD’s vascular pathology, making it the priority instruction.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

Correct Answer is A

Explanation

The nurse is developing a teaching plan for a client with peripheral arterial disease (PAD) who has a history of myocardial infarction (MI) and smokes two packs of cigarettes daily. Which instruction has the highest priority?

Correct Answer is A

Explanation

An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?

Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

The nurse is assessing a client who is admitted to the renal unit with suspected decreased renal perfusion. The nurse should plan to carefully monitor which parameter? Reference Range: Urine white blood cells (WBC) [0 to 4 WBC/low powered field (lpf)]

The nurse is teaching a client with newly diagnosed glaucoma about the condition. Which statement by the client indicates a need for further teaching?

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?