A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?
Leaves small air bubbles in the new infusion tubing.
Inserts the new device distal to the old IV site.
Wears clean gloves during the new IV insertion.
Shaves the hair on the client's skin before inserting the new IV.
The Correct Answer is C
A. Leaving small air bubbles in the new infusion tubing is incorrect. Air bubbles should be primed out of the tubing before use to prevent air embolism.
B. Inserting the new device distal to the old IV site is incorrect. The new IV site should be placed proximal to the old site to avoid complications from previous catheter use and ensure proper circulation.
C. Wearing clean gloves during the new IV insertion is correct. Clean gloves are appropriate when inserting a new short peripheral IV device. Sterile gloves are generally required for more invasive procedures, but when changing the device itself, clean gloves are sufficient.
D. Shaving the hair on the client's skin before inserting the new IV is incorrect. Shaving the skin is not recommended because it can cause small nicks that increase the risk of infection. Clipping the hair, if necessary, is the preferred method.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Blurred vision is a known adverse effect of metoclopramide. It can occur due to its effects on the central nervous system, including potential effects on visual processing. Patients should be informed about this potential side effect, and vision should be monitored periodically.
A. Metoclopramide can cause drowsiness or sedation, especially at higher doses or in susceptible individuals. Monitoring for sedation is important to ensure patient safety and adjust dosing as needed.
B. Urinary retention: Although less common, metoclopramide has been associated with urinary retention. Patients should be monitored for signs and symptoms of urinary difficulty or retention, especially if they have pre-existing urinary issues.
C. Hypertension: Metoclopramide can occasionally lead to an increase in blood pressure, particularly in patients who are predisposed to hypertension or have other cardiovascular risk factors. Blood pressure monitoring is important during treatment.
Correct Answer is D
Explanation
D. Holding the skin taut helps stabilize the area and ensures that the needle penetrates the skin smoothly and at the correct angle. This also helps prevent the needle from going too deep or slipping out of the site during injection.
A. The syringe should be held at a 5 to 15-degree angle to the client's skin, not 20 degrees.
B. For a tuberculin skin test (PPD test), typically 0.1 mL (one-tenth of a milliliter) of PPD is injected intradermally. This is a very small amount compared to 0.5 mL.
C. The length of the needle for an intradermal injection is typically shorter than 1 inch, usually around 3/8 to 5/8 inches (10-16 mm). Using a longer needle may increase the risk of inserting the needle too deeply, potentially leading to subcutaneous rather than intradermal injection.
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