A client with difficult venous access has an intravenous insertion site located at the bend of the wrist.
Which action would be most appropriate for a nurse to take?
Place the arm across the client’s chest to support the wrist.
Use a wrist restraint to decrease mobility in the arm.
Apply an arm board to immobilize the wrist.
Instruct client to limit use of that arm.
The Correct Answer is C
This is because immobilizing the wrist prevents kinking or dislodgement of the intravenous catheter and reduces the risk of complications such as infiltration, phlebitis, or infection.
Some additional information for the response are:
Choice A is wrong because placing the arm across the client’s chest may compromise venous return and increase the risk of thrombosis.
Choice B is wrong because using a wrist restraint may cause skin breakdown, nerve damage, or impaired circulation.
Choice D is wrong because instructing the client to limit use the of that arm may not be sufficient to prevent catheter movement or accidental removal.
Normal ranges for venous access depend on the type and location of the catheter, but some general values are: potassium (3 to 5 mEq/L), blood urea nitrogen (10 to 20 mg/dL), and central venous pressure (8 to 12 mmHg).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because spinach and salads contain a lot of vitamin K, which can make warfarin less effective at preventing blood clots.
Vitamin K helps the blood to clot, so eating foods high in vitamin K can counteract the effect of warfarin.
Choice A is wrong because wheat bread and butter do not contain a lot of vitamin K and do not affect warfarin.
Choice B is wrong because mangoes and tomatoes do not contain a lot of vitamin K and do not affect warfarin.
Choice D is wrong because aged cheeses and wine do not contain a lot of vitamin K and do not affect warfarin.
It is important to keep a stable diet while taking warfarin and avoid sudden changes in the amount of vitamin K intake. Foods that are high in vitamin K include green leafy vegetables, chickpeas, liver, egg yolks, avocado, and olive oil.
These foods should be limited but not eliminated from the diet. Do not drink cranberry or grapefruit juice while taking warfarin as they can increase the risk of bleeding.
Correct Answer is B
Explanation
Select a 0.5 mL syringe, 30 gauge, 8 mm needle and inject at a 90-degree angle. This is because Humulin R is a clear and colorless solution that can be given by subcutaneous injection.
A 0.5 mL syringe can hold up to 50 units of insulin, which is enough for the prescribed dose of 7 units. A 30 gauge, 8 mm needle is suitable for thin patients with poor skin turgor. Injecting at a 90-degree angle ensures that the insulin reaches the subcutaneous tissue and not the muscle.
Choice A is wrong because a 31 gauge, 6 mm needle is too short and may not deliver the insulin into the subcutaneous tissue.
Choice C is wrong because pinching the skin is not necessary for thin patients with poor skin turgor.
Choice D is wrong because a 1.0 mL syringe is too large for the prescribed dose of 7 units and may cause dosing errors. A 28 gauge, 12.7 mm needle is too long and may inject the insulin into the muscle, which can affect its absorption and action.
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