A nurse is caring for a client who has a peripheral IV catheter and a prescription for IV fluid replacement. The nurse should cover the Insertion site with which of the following types of dressing?
Transparent membrane dressing
Hydrocolloid dressing
Sterile gauze bandage
Adhesive bandage
The Correct Answer is A
A. Transparent membrane dressing:
This is the correct answer. Transparent dressings are commonly used to cover peripheral IV catheter insertion sites. They provide a clear view of the site, allow for easy monitoring, and create a barrier against contamination while maintaining a moist environment.
B. Hydrocolloid dressing:
Hydrocolloid dressings are generally used for wounds with minimal exudate. They are not typically used for securing peripheral IV catheters.
C. Sterile gauze bandage:
Sterile gauze bandages may be used for specific types of wounds but are not the preferred choice for covering peripheral IV catheter sites. Gauze dressings may increase the risk of contamination and do not provide a clear view of the site.
D. Adhesive bandage:
Adhesive bandages (commonly known as band-aids) are not suitable for covering peripheral IV catheter sites. They are typically used for small wounds or cuts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Infiltration:
Infiltration refers to the inadvertent administration of a non-vesicant solution into the surrounding tissue. It is characterized by swelling, pallor, and coolness at the infusion site, but redness and inflammation along the vein are not typical signs of infiltration.
B. Extravasation:
Extravasation occurs when a vesicant solution (a substance that can cause tissue damage) infiltrates into the surrounding tissue. It can cause tissue damage and necrosis. While inflammation is a concern with extravasation, it is not the primary sign, and redness may occur later.
C. Venous spasm:
Venous spasm involves the constriction of the blood vessel, leading to decreased blood flow. It is not typically associated with redness and inflammation along the vein.
D. Phlebitis:
This is the correct answer. Phlebitis refers to inflammation of a vein, and it is characterized by redness, warmth, and tenderness along the course of the vein. Phlebitis can be caused by various factors, including irritants in the infused solution, mechanical trauma, or infection.
Correct Answer is B
Explanation
A. I will check the client's INR before administering the heparin:
Checking the International Normalized Ratio (INR) is more relevant for monitoring the effects of warfarin, not heparin. Heparin is typically monitored by activated partial thromboplastin time (aPTT) or anti-Xa levels.
B. "I will apply pressure for 1 minute after the injection:"
Applying gentle pressure to the injection site for about 1 minute after administering heparin is appropriate to prevent bleeding or bruising. Since heparin is an anticoagulant, there's an increased risk of bleeding at the injection site.
C. I will massage the site after injecting the heparin:
Massaging the site after injecting heparin is not recommended. It can increase the risk of hematoma formation. After subcutaneous injection, it is generally advised to avoid massaging the site.
D. I will aspirate before administering the heparin:
Aspiration is not recommended when administering heparin subcutaneously, as it can increase the risk of tissue damage and bruising. The nurse should inject the heparin without aspirating.
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