While the nurse is preparing a scheduled IV medication, the client states 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?

Review the medical record for the date of insertion.

Apply ice first, then a warm compress to the IV site.

Document that the medication was not administered.

Discontinue the painful IV after a new IV is inserted.

Answer and Explanation

The Correct Answer is D

Choice A reason: Reviewing the medical record for the date of insertion is important but does not address the immediate concern of pain or potential complications at the IV site.

Choice B reason: Applying ice and then a warm compress may be used for phlebitis or infiltration, but if the client is experiencing pain, the priority is to address the potential for complications.

Choice C reason: Documentation is a necessary step, but it should not be the first action taken when a client reports pain at the IV site.

Choice D reason: If the IV site is painful, it may be indicative of infiltration, phlebitis, or another complication. The nurse should discontinue the painful IV and insert a new one at a different site to prevent further discomfort and potential harm to the client.

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Correct Answer is A

Explanation

Choice A reason: Symptoms of heartburn and pain relieved by eating can indeed be consistent with an ulcer, and a complete physical exam can help diagnose the condition and rule out other causes.

Choice B reason: While immediate medical evaluation is important, it is not specified that the symptoms are severe or life-threatening, so it may not be the best initial advice.

Choice C reason: Diet changes can help manage symptoms of heartburn and indigestion, but they may not be sufficient if an ulcer is present.

Choice D reason: It is incorrect to assure the client that the symptoms are only reflux, as ulcer pain can indeed be relieved by food, contrary to the statement.

A. Monitoring for changes in stool color is important. B. Drinking grapefruit juice will reduce the effects of the medication. C. I should take the medication with antacids. D. If I experience any difficulty with breathing, I will report it.

Correct Answer is C

Explanation

Choice A reason: Monitoring for changes in stool color can be important when taking certain medications, but it is not specifically required for itraconazole.

Choice B reason: Drinking grapefruit juice actually increases the effects of itraconazole by inhibiting its metabolism, not reducing its effects. Therefore, patients should avoid grapefruit juice while taking itraconazole.

Choice C reason: Antacids can decrease the absorption of itraconazole, making it less effective. Patients should take itraconazole with food and an acidic drink, like cola or orange juice, but not with antacids.

Choice D reason: Reporting any difficulty with breathing is appropriate advice for any medication and does not require additional instruction.

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While the nurse is preparing a scheduled IV medication, the client states 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client tells the nurse of concerns about possibly having a stomach ulcer because the client is experiencing heartburn and a dull gnawing pain that is relieved by eating. Which is the best response by the nurse?

Correct Answer is A

Explanation

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

Correct Answer is C

Explanation

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