165. A nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. Identify the sequence of actions the nurse should follow. (Move the Steps into the box on the right. placing them in the order of performance. use all the steps.)

A. Apply a tourniquet below the venipuncture site: The tourniquet should be applied above the venipuncture site to engorge the vein and make it more visible and easier to access.
B. Choose a vein that is palpable and straight: A vein that is palpable, straight, and firm provides the best chance of successful IV insertion and reduces the risk of complications like infiltration or phlebitis.
C. Elevate the client's arm prior to insertion: Elevating the arm can actually reduce venous filling and make vein access more difficult. Instead, the arm should be in a dependent position to promote vein distention.
D. Select a site on the client's dominant arm: The non-dominant arm is generally preferred for IV insertion to minimize interference with daily activities and reduce discomfort.

A. “This medication can cause back pain.": Back pain is not a common or expected adverse effect of warfarin. If the client experiences unusual pain, especially accompanied by bruising or bleeding, it may warrant further evaluation but is not directly related to the medication itself.
B. "Avoid taking this medication with milk products.”: Warfarin does not interact with milk or dairy products in the way some antibiotics do. The more important dietary concern is maintaining consistent intake of vitamin K, found in green leafy vegetables.
C. “Take the last dose of the day 1 hour before bedtime.": Warfarin is typically taken once daily at the same time, but timing relative to bedtime is not critical. The key point is consistency and routine INR monitoring, not the hour of the day.
D. "Use an electric razor when shaving while taking this medication.": Warfarin increases bleeding risk, so using an electric razor helps minimize the chance of cuts and bleeding during shaving. This is a standard safety recommendation for clients on anticoagulants.