A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following is an appropriate action for the nurse to take?

Choose a vein that is soft on palpation.

Select a vein in the client's dominant arm.

Select a site distal to previous venipuncture attempts.

Choose the most proximal vein in the extremity.

Answer and Explanation

The Correct Answer is C

A. Choosing a vein that is soft on palpation may indicate it's not suitable for IV insertion. A vein with a slight bounce or resilience is preferable.
B. Selecting a vein in the client's dominant arm is not a primary consideration. Both arms are

usually suitable, and the choice depends on factors such as accessibility and patient preference.

C. Selecting a site distal to previous venipuncture attempts reduces the risk of complications such as infiltration or infection and allows for optimal vein preservation.
D. Choosing the most proximal vein in the extremity is not typically recommended for peripheral IV insertion. Veins more distal to the body are often preferred for initial attempts, with
consideration for vein integrity and accessibility.

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Correct Answer is A

Explanation

A. If the nurse still has concerns after seeking clarification, the appropriate action is to contact another provider for a second opinion to ensure the safety and well-being of the client.
B. Withholding the treatment without further consultation may not be the best course of action.
Seeking additional input is important.
C. Carrying out the prescription despite concerns about its safety may pose risks to the client.
D. Notifying the ethics committee should be considered if there are ongoing ethical concerns or if the issue cannot be resolved through collaboration with other providers.

A. Obtain apical and radial rates simultaneously. B. Palpate pulses in the lower extremities. C. Check blood pressure in left and right arms. D. Compare the pulse strength in upper extremities.

Correct Answer is A

Explanation

A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).

B. Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.

C. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.

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