A nurse is assessing a client who is postpartum and has developed endometritis.
Which of the following findings should the nurse expect?

Choice A rationale

While larger gauge catheters (e.g., 18-gauge) are used for rapid infusion, they also cause more trauma to the vein's intimal layer during insertion. This trauma can trigger a localized inflammatory response, increasing the risk of phlebitis, which is inflammation of the vein. Smaller gauge catheters (e.g., 22-24 gauge) cause less trauma and are preferred for routine fluid administration to prevent this complication.

Choice B rationale

The non-dominant arm is the preferred site for IV access whenever possible. Using the non-dominant arm allows the client to maintain more normal function and independence with daily activities, as they can still use their dominant hand without the restriction of the IV line. This also minimizes the risk of accidental dislodgement or trauma to the site.

Choice C rationale

Selecting a site proximal to previous venipuncture sites is the recommended practice. When a vein is punctured, it can cause localized inflammation and scar tissue formation distal to the site. Starting proximal allows for the use of a healthier segment of the vein, which improves the likelihood of successful insertion and reduces the risk of extravasation or phlebitis.

Choice D rationale

The palmar side of the client's wrist should be avoided for IV insertion. This area contains a high concentration of nerves and tendons, including the median nerve and radial artery. Inserting a catheter here increases the risk of nerve damage, which can lead to permanent numbness, tingling, or pain, and also increases the risk of arterial puncture. *.

Choice A rationale

A child with a Wilms' tumor and an abdominal mass requires urgent attention and management. However, this is not an immediate life-threatening emergency. The primary concern is to avoid palpating the abdomen to prevent rupture of the encapsulated tumor, which could disseminate cancer cells. This is a critical care consideration but does not represent an immediate threat to the child's airway or circulation, which would be prioritized in triage.

Choice B rationale

A child with a urinary tract infection and bright red blood in their urine, or hematuria, requires a thorough assessment and medical intervention. Hematuria can indicate a significant underlying problem, but it does not represent an immediate threat to the child's airway, breathing, or circulation. The child's condition is stable compared to a child with an impending airway obstruction. This client would be assessed after more critical clients.

Choice C rationale

A child with mononucleosis reports severe fatigue, which is a common and expected symptom of the illness. The primary concern with mononucleosis is often splenic rupture, especially if the child is engaging in strenuous activity. However, fatigue itself is not an immediate life-threatening condition. This child would be assessed after more critical clients, as their airway and breathing are not compromised.

Choice D rationale

A child with acute epiglottitis who is drooling is the highest priority for assessment. This finding, combined with the diagnosis, is a classic sign of an impending airway obstruction due to the inflamed epiglottis. The child is unable to swallow their own saliva, indicating significant swelling. This is a medical emergency that can rapidly progress to complete airway occlusion and respiratory arrest, requiring immediate intervention to secure the airway. *.