A nurse is caring for a client who has a prescription for parenteral therapy. Which of the following actions should the nurse take when initiating IV therapy?
Insert the IV catheter using the Z-track technique.
Insert the IV catheter with the bevel down.
Remove the roller clamp from the tubing prior to IV insertion.
Apply the tourniquet 5 to 10 cm (about 2 to 4 in) above the IV insertion site.
The Correct Answer is D
A. "Insert the IV catheter using the Z-track technique." The Z-track technique is used for intramuscular (IM) injections, not IV therapy.
B. "Insert the IV catheter with the bevel down." The bevel should be up to facilitate smooth vein entry.
C. "Remove the roller clamp from the tubing prior to IV insertion." The roller clamp should remain in place to control fluid flow and prevent air from entering the tubing.
D. "Apply the tourniquet 5 to 10 cm (about 2 to 4 in) above the IV insertion site." This placement helps distend the vein for easier cannulation without restricting arterial blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "The client's room number and diagnosis are written on the hallway communication board." This is a breach of client confidentiality because it publicly displays protected health information (PHI) where unauthorized individuals, including visitors and non-essential staff, could see it. This violates HIPAA (Health Insurance Portability and Accountability Act) regulations.
B. "The history and physical in the electronic medical record describes the client's previous suicide attempt." The electronic medical record (EMR) is a secure and appropriate place for documenting the client's health history. Access is restricted to healthcare providers involved in the client’s care.
C. "The time when the client can next have pain medication is written on their bedside communication board." This does not violate confidentiality, as it is relevant to the client’s direct care and is visible only to the healthcare team and the client.
D. "The client is wearing a color-coded bracelet that states they are a fall risk." Color-coded bracelets are a standard safety practice in hospitals to communicate important patient care needs to staff. This does not disclose specific medical information beyond the fall risk status.
Correct Answer is D
Explanation
A. Tertiary care Tertiary care refers to specialized medical care provided in hospitals for complex conditions (e.g., ICU care, cancer treatment, neurosurgery). It is not a self-care resource for caregivers.
B. Restorative care Restorative care focuses on rehabilitation and regaining function (e.g., physical therapy, speech therapy) rather than providing relief for caregivers.
C. Telemedicine care Telemedicine involves remote medical consultations, which can benefit clients but does not specifically address caregiver self-care needs.
D. Respite care Respite care provides temporary relief for caregivers by arranging for short-term professional care of their loved ones. This helps prevent caregiver burnout and supports self-care for those providing long-term assistance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
