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These findings indicate IV infiltration. The first action is to stop the infusion and remove the IV catheter. Warm or cold compresses may follow depending on the solution infiltrated. Slowing the infusion (Option A) is unsafe, as it worsens the problem. Documentation (Option D) is important but not the priority. This falls under Safe and Effective Care Environment—Safety and Infection Control. NCLEX emphasizes prompt recognition of IV complications and prioritizing client safety.

Hypoglycemia (<70 mg/dL) requires immediate administration of fast-acting carbohydrates. Option B follows if symptoms don’t improve. Option C delays treatment. Option D is not priority. This falls under Physiological Integrity—Pharmacological Therapies. NCLEX prioritization requires prompt recognition and intervention for hypoglycemia.

Option B validates the client’s feelings and encourages expression. Options A, C, and D minimize or dismiss the client’s experience. This falls under Psychosocial Integrity—Therapeutic Communication. NCLEX emphasizes empathetic responses to support mental health clients.

The “three checks” (before removing the drug, when preparing it, and at the bedside before giving it) ensure medication accuracy. Option A is unsafe—clients may be mistaken. Option C increases risk of error. Option D is unsafe—leaving meds unattended can result in missed or incorrect doses. This falls under Safe and Effective Care Environment—Safety and Infection Control. NCLEX emphasizes the “five rights” of medication administration and consistent adherence to safety protocols.

A respiratory rate of 8 indicates opioid-induced respiratory depression, a life-threatening side effect requiring immediate intervention (e.g., hold the dose, administer naloxone). Constipation, nausea, and itching are common but manageable side effects. This falls under Physiological Integrity—Pharmacological Therapies. NCLEX requires nurses to recognize priority adverse effects, particularly those affecting airway and breathing. Nurses must assess respiratory rate, oxygenation, and sedation before opioid administration and act promptly to prevent overdose-related complications.