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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

While the supervisor of the neurology unit may have expertise in neurology, they are not typically responsible for coordinating the progression of a patient’s care following a spinal cord injury.

Choice B rationale

The nurse in charge of risk management is typically responsible for identifying and evaluating risks in the healthcare setting. They are not typically involved in the direct management of a patient’s care.

Choice C rationale

The nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including spinal cord injuries. They work with the patient, family, and healthcare team to develop a comprehensive care plan.

Choice D rationale

While an adult nurse practitioner can provide a high level of care, they are not typically responsible for managing the progression of a patient’s care following a spinal cord injury.

A. Reassure the client that the nurse will return after all vital signs are taken. B. Pull up a chair and sit beside the client’s bed. C. Allow the client to hold the nurse’s hand until the vital signs can be completed. D. Tell the client that he must release the nurse’s hand.

Correct Answer is B

Explanation

Choice A rationale

Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.

Choice B rationale

Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.

Choice C rationale

Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.

Choice D rationale

Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.

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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?

Nursing Test Bank

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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?