While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?
Apply ice then a warm compress to the IV site.
Discontinue the IV site after inserting a new access.
Redress the IV site while assessing for redness.
Review the medical record for the date of insertion.
The Correct Answer is B
Rationale
A. Applying ice or a warm compress without assessing the site could potentially worsen any underlying issue.
B. The appropriate intervention would be to discontinue the IV site after ensuring a new access is established. This is because continuing to use a painful IV site can lead to complications such as infiltration or phlebitis.
C. Redressing the site without assessment does not address the client's complaint of pain.
D. Checking the medical record provides information about when the IV was inserted, which can be important for assessing the site's viability and expected duration. However, it doesn't address the immediate concern of the client's pain at the site or refusal of a flush.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Dill pickles and black olives are typically high in sodium due to the pickling process. High sodium intake can exacerbate hypertension by increasing fluid retention and raising blood pressure.
B. Canned chicken broth often contains a high amount of sodium unless it is specifically labeled as low sodium or reduced sodium. Barley itself is a nutritious whole grain, but the sodium content in canned broth might counterbalance its benefits.
C. Tomato juice can be a good choice for someone with hypertension as long as it is low in sodium or sodium-free. Tomatoes are rich in potassium and other nutrients beneficial for heart health. Gluten-free crackers can be a healthy addition if they are low in sodium and made from whole grains.
D. Sweet potatoes are a nutrient-dense food high in potassium, fiber, and various vitamins and minerals. They are naturally low in sodium and are considered heart-healthy due to their potassium content, which helps counteract the effects of sodium on blood pressure.
Correct Answer is D
Explanation
Rationale
A. The complement system is part of the immune response and can be activated in various conditions, including sepsis. However, activation of complement pathways does not directly cause DIC. Instead, in septic shock, the release of pro-inflammatory cytokines and tissue factor can trigger systemic coagulation activation, leading to DIC.
B. Inhibition of red blood cell production, such as in conditions like aplastic anemia or certain types of bone marrow disorders, does not directly cause DIC. DIC is primarily a disorder of excessive activation of clotting factors in response to underlying conditions like sepsis, trauma, or cancer.
C. Production of extra platelets, or thrombocytosis, is not the cause of DIC. Thrombocytosis can occur in response to various conditions, but DIC involves consumption of platelets due to widespread activation of clotting within the vasculature.
D. DIC is characterized by the widespread consumption and depletion of clotting factors and platelets as they are used up in the formation of microthrombi throughout the bloodstream. This depletion leads to an increased risk of bleeding due to insufficient clotting factors remaining to maintain hemostasis.
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