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 A
Explanation
Cataracts are a condition where the lens of the eye becomes opaque, causing impaired vision. Blurred or cloudy vision is a common symptom of cataracts.
Some possible explanations for the other choices are:
Choice B. Burning sensation in the eye. This is not a typical symptom of cataracts, but it could indicate an infection, allergy, or dry eye syndrome.
Choice C. Inability to produce tears. This is also not a typical symptom of cataracts, but it could indicate a problem with the lacrimal glands or ducts that produce and drain tears.
Choice D. A swollen lacrimal gland. This is not a symptom of cataracts, but it could indicate an inflammation or infection of the lacrimal gland, which is located near the upper eyelid.
Normal ranges for visual acuity are 20/20 for normal vision and 20/40 for mild impairment. Visual acuity can be measured using a Snellen chart or other methods.
Correct Answer is B
Explanation
What is your understanding of the situation?”. This is a therapeutic response because it respects the client’s autonomy and invites them to share their concerns and feelings about the surgery.
Choice A is wrong because it is authoritarian and dismissive of the client’s feelings. It does not acknowledge the client’s right to refuse treatment.
Choice C is wrong because it is nontherapeutic and shows agreement with the client’s refusal. It also implies that the nurse and the doctor are on different sides.
Choice D is wrong because it is manipulative and guilt-tripping. It implies that the client does not care about their loved ones or their own life.
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