The nurse is assigned a post-operative total hip replacement patient reporting incisional pain that is not managed with current pain medications.
Complete the following sentence using the drop-downs.
The nurse should determine whether the IV line is
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"A"}
Rationale for Correct Answer:
- Patent: The nurse should determine whether the IV line is patent because a patent line ensures that medications flow freely and effectively reach the bloodstream for pain relief.
- Obstruction: The nurse should determine whether the IV line is obstructed because obstruction prevents the flow of medication through the IV line, interfering with the effectiveness of the prescribed medications.
- Medication delivery: The nurse should determine whether the IV line is obstructed because obstruction directly interferes with medication delivery, preventing pain medications from being delivered as intended.
Rationale for Incorrect Choices:
- Properly secured: While it is important for the IV line to be properly secured, this does not affect the ability of the medication to flow or reach the bloodstream. The IV line can still be obstructed even if it is properly secured, which would block medication delivery.
- Malpositioned: If the IV line is malpositioned, this could reduce the flow of medication, but it does not completely prevent medication from being delivered. Obstruction is the primary concern for ensuring the effective delivery of medication.
- Extravasation: Extravasation occurs when IV medication leaks into surrounding tissue, causing tissue damage. While this is a serious issue, it doesn’t directly affect the ability of the medication to reach the bloodstream. Obstruction is a more immediate concern as it prevents medication delivery entirely.
- Infiltration: Infiltration happens when IV medication leaks into surrounding tissues, leading to tissue damage. However, it does not stop the medication from reaching the bloodstream, unlike obstruction, which completely prevents medication delivery.
- Phlebitis: Phlebitis refers to vein inflammation, which could cause tissue damage or discomfort, but it doesn't usually obstruct the IV line completely. Obstruction, however, directly impacts medication delivery and is more critical for this patient.
- Fluid administration: Fluid administration does not directly affect the delivery of pain medications. While fluids may be necessary for hydration, obstruction in the IV line is the primary issue in ensuring the correct pain medications are delivered effectively.
- Tissue damage: Tissue damage caused by extravasation, infiltration, or phlebitis can occur when the IV line is not functioning properly, but this is secondary to the concern of whether the IV line is patent for proper medication delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Weight: Weight changes can occur due to fluid shifts and edema, but it is not a primary indicator of adequate fluid resuscitation. In burn patients, weight fluctuation may not reliably reflect the effectiveness of fluid replacement.
B. Urine output: Urine output is closely monitored in burn patients for signs of fluid resuscitation adequacy. However, if urine output continues to decrease (instead of increasing), it suggests worsening kidney perfusion and fluid depletion.
C. BP: In burn patients, low blood pressure is a sign of fluid loss and inadequate perfusion. While blood pressure will eventually improve with successful fluid resuscitation, a further decrease in BP would indicate worsening shock and fluid deficit, not adequate resuscitation.
D. Heart rate: A decrease in heart rate would indicate that the body is no longer compensating for hypovolemia and shock. Tachycardia is a common response to fluid loss and hypotension in burn patients, and as fluid resuscitation is effective, the heart rate should begin to decrease toward normal levels.
Correct Answer is C
Explanation
A. Furosemide: Furosemide is a diuretic used to manage fluid overload and edema, typically in conditions like heart failure or kidney disease. It does not address the immediate life-threatening symptoms of anaphylactic shock, such as airway constriction and hypotension.
B. Dobutamine: Dobutamine is an inotropic agent used to increase cardiac output in cases of heart failure or shock related to low cardiac output. It is not the first-line treatment for anaphylactic shock, where airway management and vasoconstriction are the priorities.
C. Epinephrine: Epinephrine is the first-line treatment for anaphylactic shock. It works rapidly to reverse the life-threatening symptoms of anaphylaxis by causing vasoconstriction (to raise blood pressure), relaxing bronchial smooth muscle (to alleviate airway constriction), and inhibiting further release of histamine.
D. Methylprednisolone: Methylprednisolone is a corticosteroid used to reduce inflammation and immune responses. However it does not address the immediate, life-threatening symptoms of anaphylactic shock, such as bronchoconstriction and hypotension.
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