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.
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Related Questions
Correct Answer is C
Explanation
A. Inform the client they cannot refuse the surgery once the consent form has been signed. A client has the right to refuse treatment at any time, even after signing a consent form.
B. Explain the risks of the surgery to the client. The provider is responsible for explaining the risks, benefits, and alternatives of the procedure. The nurse's role is to witness consent and ensure the client understands.
C. Ensure the client has advance directives on file. Since the client has a serious, life-threatening illness (stage 4 cancer) and is undergoing surgery, it is important to verify whether they have advance directives, such as a living will or durable power of attorney for healthcare. These documents ensure that their wishes regarding medical treatment are followed.
D. Ask the client if they wish to be resuscitated in the event they stop breathing. While this is an important conversation, it is typically initiated by the provider. The nurse should confirm whether the client has a Do Not Resuscitate (DNR) order or advance directives in place.
Correct Answer is C
Explanation
A. Give the adolescent a short story pamphlet about puberty. While educational materials about puberty can be helpful, they do not provide specific information about a pelvic examination.
B. Describe the steps to the adolescent's guardian. The explanation should be directed to the adolescent to ensure they understand and feel comfortable. The guardian may be included if the adolescent prefers.
C. Show an online video that demonstrates what to expect. A visual demonstration can help reduce anxiety by familiarizing the adolescent with the procedure in a clear and informative way.
D. Use an anatomically correct puppet to demonstrate. Puppets are more appropriate for explaining procedures to younger children, not adolescents.
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