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A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids.
Which of the following actions should the nurse take?

A.

Initiate IV access on the palmar side of the client's wrist.

B.

Insert a larger gauge IV catheter to prevent phlebitis.

C.

Choose the client's dominant arm for IV access whenever possible.

D.

Select a site proximal to previous venipuncture sites.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Initiating IV access on the palmar side of the client's wrist is not recommended. This area has many delicate structures and is prone to complications such as nerve damage. Choosing a safer, larger vein proximal to the wrist is a better practice.

Choice B rationale:

Inserting a larger gauge IV catheter is not necessary unless the client's condition or prescribed therapy specifically requires it. Using an unnecessarily large catheter can cause discomfort and increase the risk of complications, such as phlebitis.

Choice C rationale:

Choosing the client's dominant arm for IV access whenever possible is not a universally appropriate guideline. The choice of the arm should depend on the condition of the veins and the individual patient's circumstances. The nurse should assess both arms and choose the one with the most suitable and accessible veins.

Choice D rationale:

Selecting a site proximal to previous venipuncture sites is the correct action. Repeated venipuncture in the same area can cause phlebitis and compromise the integrity of the veins. Selecting a new site proximal to previous punctures helps to preserve vein health and reduce the risk of complications.


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Related Questions

Correct Answer is A

Explanation

- A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.

- B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.

- C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.

- D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.

Correct Answer is D

Explanation

Verify the client and blood product information with another licensed nurse.

Rationale:

  1. A - This is not a correct procedure for client identification, but rather for blood compatibility. The nurse should check the client's blood type and crossmatch it against the blood product label, not the provider's orders.
  2. B - This is not a reliable method of client identification, as the client may not know or remember their blood type correctly. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.
  3. C - This is not a relevant step for client identification, but rather for informed consent. The nurse should ensure that the client has signed an informed consent form before administering blood, but this does not verify that the blood product matches the client.
  4. D - This is the correct procedure for client identification, as it involves two licensed nurses who independently check and confirm the client's identity and the blood product information, such as blood type, Rh factor, expiration date, and serial number.

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