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 C

Explanation

Choice A reason: Discussing time-checking does not address compulsive lock-checking, likely obsessive-compulsive disorder (OCD), driven by serotonin dysregulation causing intrusive fears. Time management is unrelated to compulsions. Planning activities reduces idle time, distracting from OCD behaviors, addressing the neurobiological basis more effectively.

Choice B reason: Asking why the client checks locks may heighten anxiety in OCD, as compulsions arise from irrational fears, not logic, via cortico-striatal-thalamic dysfunction. This may reinforce obsessions. Activity planning distracts from compulsions, offering a therapeutic approach to improve function, making questioning less effective.

Choice C reason: Planning daily activities structures time, reducing compulsive lock-checking in OCD, where obsessive fears disrupt function. Engaging tasks modulate serotonin, distracting from cortico-striatal overactivity, improving behavioral control. This addresses the disorder’s impact, enhancing functionality by minimizing compulsion opportunities, making it the best action.

Choice D reason: Determining lock type is irrelevant to OCD’s compulsive checking, rooted in neurobiological fear responses, not lock characteristics. This does not address serotonin imbalance. Activity planning redirects focus to structured tasks, reducing compulsions, making lock assessment ineffective for managing the client’s behavior.

A. Take the medication on an empty stomach. B. Report any signs of gastrointestinal bleeding. C. Wear a high intensity sunblock when outside. D. Monitor blood pressure frequently.

Correct Answer is B

Explanation

Choice A reason: Taking ibuprofen on an empty stomach increases gastrointestinal irritation, as NSAIDs inhibit prostaglandins, reducing gastric mucus protection. This risks gastritis or ulcers. Taking it with food minimizes irritation, making this instruction incorrect and potentially harmful for clients managing chronic arthritic pain with ibuprofen.

Choice B reason: Ibuprofen, an NSAID, risks gastrointestinal bleeding by inhibiting prostaglandins, weakening stomach lining protection, and impairing platelet aggregation. Symptoms like black stools or hematemesis indicate serious complications. Reporting these ensures early intervention, preventing severe outcomes like perforation or anemia, making this a critical instruction for safe use.

Choice C reason: High-intensity sunblock is relevant for photosensitizing drugs (e.g., doxycycline), not ibuprofen, which does not significantly increase photosensitivity. NSAIDs primarily affect cyclooxygenase pathways, not skin UV sensitivity. Reporting gastrointestinal bleeding is more critical, as it addresses a common, severe side effect requiring urgent attention.

Choice D reason: Ibuprofen can elevate blood pressure via sodium retention and vasoconstriction, but this is less common at standard doses. Gastrointestinal bleeding is a more frequent, severe risk, as NSAIDs disrupt gastric mucosa. Reporting bleeding symptoms takes precedence to prevent life-threatening complications, making blood pressure monitoring secondary.

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Naxlex Comprehensive Predictor Exams

A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

Correct Answer is C

Explanation

Which instruction should the nurse include in the discharge teaching plan of a client who is prescribed ibuprofen for arthritic pain?

Correct Answer is B

Explanation

Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?

A client with a history of schizophrenia, and drug and alcohol abuse is admitted to the hospital for hepatitis. The nurse should contact the healthcare provider before implementing which prescription?

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

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

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?