While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.
What should the nurse do next?
Apply ice, then a warm compress to the IV site.
Check the medical record for the date of IV insertion.
Redress the IV site while checking for redness.
Discontinue the current IV site and insert a new one.
The Correct Answer is D
Choice A rationale
Applying ice, then a warm compress to the IV site may help with pain or inflammation, but it does not address the potential problem with the IV site itself. If the client is experiencing pain and refuses a flush to assess the site, it could indicate that the IV site is compromised.
Choice B rationale
Checking the medical record for the date of IV insertion could provide useful information about how long the IV has been in place, but it does not directly address the client’s current complaint of pain at the IV site.
Choice C rationale
Redressing the IV site while checking for redness could help identify signs of infection or inflammation, but it does not address the client’s complaint of pain or their refusal to have the site flushed.
Choice D rationale
Discontinuing the current IV site and inserting a new one is the most appropriate action in this situation. If the client is experiencing pain at the IV site and refuses a flush to assess the site, it suggests that the current IV site may be compromised. Inserting a new IV ensures that the client can continue to receive their scheduled IV medication safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
D.
Choice A rationale
Checking capillary refill on bilateral upper extremities can help assess peripheral circulation and identify any potential vascular injuries.
Choice B rationale
Administering morphine 2 mg IV as ordered would help manage the patient’s pain.
Choice C rationale
Performing range of motion exercises may not be appropriate immediately after the fall and before the extent of the patient’s injuries are fully assessed.
Choice D rationale
Administering ondansetron 4 mg IV as ordered can help manage any nausea or vomiting that the patient may experience, which can be a side effect of the morphine or a result of the fall itself. TemazepamTemazepam Explore
Correct Answer is A
Explanation
Choice A rationale
Watery diarrhea is a significant side effect of linezolid and could indicate a serious condition called antibiotic-associated colitis, which is caused by an overgrowth of the bacterium Clostridium difficile. This condition requires immediate medical attention.
Choice B rationale
Increased fatigue is a common side effect of many medications, including linezolid. While it should be reported to the healthcare provider, it is not as urgent as watery diarrhea.
Choice C rationale
Nausea and headache are common side effects of linezolid. While they should be reported to the healthcare provider, they are not as urgent as watery diarrhea.
Choice D rationale
Yellow-tinged sputum could indicate an infection or other lung condition. However, in the context of a patient receiving linezolid for nosocomial pneumonia, it is not as urgent as watery diarrhea.
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