The client's IV. placed near the right antecubital space, is running very slowly but does not appear infiltrated and does not have evidence of phlebitis. Which measure should the nurse implement to attempt to improve the flow rate of the IV?
Alter the client's arm position
Place the IV on an infusion pump
Lower the height of the IV pole
Open the clamp as far as possible for one hour
The Correct Answer is A
A. Changing the client's arm position, such as raising or lowering it, could potentially improve flow by altering the gravitational pull on the IV solution. For example, raising the arm could increase flow due to increased pressure, while lowering it could decrease flow. However, this approach may not always be effective and should be done cautiously to avoid discomfort or compromising the integrity of the IV site.
B. Using an infusion pump can help regulate the flow rate of the IV solution more accurately compared to gravity alone. However, if the IV is running slowly due to factors unrelated to the infusion rate setting, such as a partial blockage or resistance in the IV line, using an infusion pump may not necessarily improve the flow rate.
C. Lowering the height of the IV pole can increase the gravitational force acting on the IV solution, potentially improving flow. This adjustment can help overcome minor obstructions in the IV line and facilitate better flow. However, it should be done cautiously to avoid excessive pressure on the IV site or causing discomfort to the client.
D. Opening the clamp fully for an extended period is not a recommended approach. It could lead to rapid infusion or an excessive flow rate, increasing the risk of complications such as fluid overload or vein irritation. Additionally, this action does not address the underlying reason for the slow flow rate and may not effectively resolve the issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This statement demonstrates an understanding of palliative care as a supportive approach focused on optimizing independence and quality of life. Palliative care emphasizes symptom management, psychosocial support, and enhancing functional abilities to enable patients to live as fully and independently as possible, even in the context of a progressive neurologic disease. This statement aligns with the principles of palliative care, which aim to empower patients to make choices and maintain control over their lives.
A. This statement reflects a perception of palliative care as solely placing the responsibility of care on the family. While family support is an essential component of palliative care, it is not the sole responsibility of the family. Palliative care aims to provide comprehensive support to patients with serious illnesses, addressing physical, emotional, social, and spiritual needs. It involves a collaborative approach involving healthcare professionals, patients, and their families to ensure holistic care and quality of life.
C. This statement suggests a misconception about palliative care, equating it with relinquishing control of care decisions to a partner or caregiver. In reality, palliative care emphasizes patient-centered decision-making and supports patients in expressing their preferences, values, and goals of care. While caregivers play an important role in the palliative care team, ultimate decision-making authority rests with the patient, and care plans are tailored to align with the patient's wishes and priorities.
D. This statement reflects a misunderstanding of palliative care as a replacement for disease-specific medical care, such as neurology. Palliative care is not mutually exclusive with disease-focused treatment but rather complements it by addressing the broader physical, emotional, and social needs of patients with serious illnesses, including progressive neurologic diseases. Palliative care can be provided concurrently with disease-specific treatments and involves a multidisciplinary team, which may include specialists like neurologists, to ensure comprehensive care.
Correct Answer is A
Explanation
A. This statement suggests that the client may have sleep-disordered breathing, such as obstructive sleep apnea, which can disrupt the client's sleep patterns and affect their overall sleep quality. The nurse may want to inquire further about the frequency and severity of the snoring, as well as any associated symptoms such as daytime fatigue or observed pauses in breathing during sleep.
B. This statement indicates that emotional stressors, such as arguments or conflicts, may impact the client's sleep patterns. The nurse may want to explore how often these conflicts occur and how they affect the client's ability to fall asleep or stay asleep. Additionally, the nurse may inquire about coping strategies or interventions that the client and their partner use to address conflicts and minimize their impact on sleep.
C. This statement suggests that the client experiences deep or heavy sleep, which may or may not be problematic depending on the context. While deep sleep can be indicative of good sleep quality, it may also raise concerns about the client's ability to awaken in the event of an emergency or the presence of a sleep disorder such as hypersomnia. The nurse may want to inquire further about the client's overall sleep duration, sleep latency, and any difficulties with waking up in the morning.
D. This statement suggests that the client may experience sleep talking, which is a common sleep phenomenon. While sleep talking itself is typically benign, it may indicate underlying sleep disturbances such as sleep fragmentation or abnormal sleep cycles. The nurse may want to ask additional questions to assess the frequency and content of the sleep talking, as well as any potential impacts on the client's sleep quality or daytime functioning.
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