A nurse is preparing to remove a peripheral IV for a preschooler. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Inspect the IV catheter tip

Apply firm pressure at the IV site.

Remove the IV catheter while keeping the catheter hub parallel to the insertion site.

Allow the preschooler to assist with removing the transparent dressing over the IV

Turn off the IV infusion pump and damp the y tubing

Answer and Explanation

The Correct Answer is E,D,C,B,A

E: The first step is to turn off the IV infusion pump and clamp the IV tubing to prevent air from entering the line and to stop the flow of medication or fluids.

D: Next, allowing the preschooler to assist with removing the transparent dressing can help in reducing anxiety and providing a sense of control, which is important for a child's emotional well-being during medical procedures.

B: Applying firm pressure at the IV site after the catheter is removed helps to prevent bleeding and ensures the closure of the venipuncture site.

C: Removing the IV catheter while keeping the catheter hub parallel to the insertion site minimizes discomfort and the risk of damaging the vein.

A: Finally, inspecting the IV catheter tip after removal is essential to ensure that the entire catheter has been removed and that no part has been left in the vein.

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Correct Answer is A

Explanation

- Rationale for A: Serving meals with plastic utensils is a safety measure to prevent self-harm. Metal utensils can be used as weapons, so plastic is a safer alternative. This action reflects the priority of maintaining a safe environment for the client.
- Rationale for B: Assigning another client to accompany the client to therapy sessions is not advisable. It may violate privacy and confidentiality, and it is not the responsibility of other clients to monitor safety.
- Rationale for C: Assigning the client to a private room could be beneficial for monitoring purposes, but it does not directly prevent self-harm. It is also important to consider that constant observation is necessary regardless of room assignment.
- Rationale for D: Checking on the client every 4 hours is not sufficient for a client who is at high risk for suicide. More frequent monitoring is needed to ensure the client's safety and to intervene promptly if necessary.

A. Puncture the heel to a depth of 4 mm to obtain the specimen. B. Withhold feeding prior to collecting the specimen. C. Apply a heat pack 5 to 10 min prior to the procedure. D. Elevate the newborn's foot for 15 min following the procedure.

Correct Answer is C

Explanation

Choice A Rationale: Puncturing the heel to a depth of 4 mm may be too deep and could cause injury to the newborn's foot. The recommended depth is usually less than 2 mm to avoid damaging underlying bone or tissues.
Choice B Rationale: Withholding feeding prior to collecting the specimen is not necessary and could cause unnecessary distress to the newborn. Feeding can help in soothing the infant and may even improve blood flow for the procedure.
Choice C Rationale: Applying a heat pack 5 to 10 minutes prior to the procedure is recommended as it helps to increase blood flow to the area, making the collection easier and potentially less painful for the newborn.
Choice D Rationale: Elevating the newborn's foot for 15 minutes following the procedure is not a standard recommendation. Post-procedure care typically involves applying gentle pressure to stop bleeding and then covering the puncture site with a bandage.

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A nurse is preparing to remove a peripheral IV for a preschooler. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

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Correct Answer is A

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A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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