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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Rationale

A. This finding suggests that the skin has already broken down, indicating a more advanced stage of pressure injury rather than an early indication. The presence of broken skin typically indicates at least a Stage 2 pressure injury according to the staging system.

B. This description suggests the presence of a deep tissue injury (DTI), which is a late sign of pressure injury.

C. This is indicative of a stage I pressure injury, where the skin is still intact but shows signs of redness that does not blanch with pressure. This stage precedes the actual breakdown of skin seen in more advanced pressure injuries.

D. This finding describes a superficial wound with clear margins, suggesting a Stage 2 pressure injury. It is more advanced than the early signs typically sought for early intervention.

A. Volume of pedal pulses. B. Length of capillary refill. C. Rhythm of apical pulse. D. Degree of skin elasticity.

Correct Answer is C

Explanation

Rationale

A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.

B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.

C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.

D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.

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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?

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Naxlex Comprehensive Predictor Exams

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