The nurse is preparing to start an IV for a client who is combative. What precautionary measure should the nurse take in order to avoid a needlestick?

Have the client placed in restraints.

Refuse to start the IV.

Give the client a sedative prior to starting the IV.

Ask for assistance.

Answer and Explanation

The Correct Answer is D

A. Have the client placed in restraints: Restraints should only be used as a last resort when the client poses a danger to themselves or others. They require a provider’s order and must follow strict guidelines. It is not the first step in managing a combative client.
B. Refuse to start the IV: Refusing care delays necessary treatment and does not address the issue of safety. The nurse has a duty to provide care using appropriate support and safety measures.
C. Give the client a sedative prior to starting the IV: Administering a sedative requires a provider's order and should not be done solely for ease of IV insertion. Sedation is not a routine intervention and must be clinically justified.
D. Ask for assistance: Having another trained staff member present increases safety and reduces the risk of needlestick injury. Assistance ensures proper restraint of movement without violating patient rights or safety protocols.

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Correct Answer is B

Explanation

A. "I am ordered a bronchodilator to note lung improvement following use.": Pulmonary function tests often include a bronchodilator challenge to evaluate how much lung function improves after medication, which helps assess reversibility of airway obstruction.
B. "I will breathe in through my mouth and out through my nose.": Spirometry requires breathing in and out through the mouth while using a mouthpiece, not through the nose. This ensures accurate airflow measurement and prevents air from bypassing the device.
C. "I brought comfortable clothes and shoes for the test.": Wearing loose, comfortable clothing is encouraged to avoid restricting chest expansion during the test. This statement reflects good preparation for the procedure.
D. "My study is scheduled for 10 AM, several hours after I eat.": Scheduling pulmonary function tests a few hours after eating is appropriate, as a full stomach may restrict lung expansion or cause discomfort during forced breathing maneuvers.

A. Hydroxyurea B. Anticholinergics C. Disinhibitors D. Reverse transcriptase inhibitors

Correct Answer is D

Explanation

A. Hydroxyurea: Hydroxyurea is a chemotherapeutic agent primarily used in conditions like sickle cell disease and some cancers. It is not part of standard antiretroviral therapy (ART) for HIV management.
B. Anticholinergics: Anticholinergics are used to reduce secretions or treat conditions like asthma and overactive bladder. They are not used in the treatment of HIV and do not affect viral replication.
C. Disinhibitors: "Disinhibitors" is not a recognized pharmacological class in the treatment of HIV. The term "disinhibitor" might be used in other contexts, such as describing the effects of certain substances on behavior, but it's not a pharmacological classification for HIV medications.
D. Reverse transcriptase inhibitors: These are a cornerstone of HIV treatment. They inhibit the reverse transcriptase enzyme, which the virus uses to convert its RNA into DNA. This class includes both NRTIs and NNRTIs and is typically used in combination therapy.

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The nurse is preparing to start an IV for a client who is combative. What precautionary measure should the nurse take in order to avoid a needlestick?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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