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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 it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.
  • B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.
  • C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.
  • D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.

Correct Answer is C

Explanation

- A. The LPN and AP lower the side rails before lifting the client up in bed is incorrect. This is a safe practice that prevents injury to the client and staff by providing more space for movement and reducing the risk of falling.

- B. Prior to lifting the client, the LPN and AP raise the bed to waist level is incorrect. This is a safe practice that prevents injury to the client and staff by reducing the need for bending and lifting.

- C. The LPN and the AP grasp the client under his arms to lift him up in bed is correct. This is an unsafe practice that can cause injury to the client's shoulders, neck, and axillae by applying excessive pressure and friction. The LPN and AP should use a draw sheet or a mechanical lift device to move the client up in bed.

- D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift is incorrect. This is a safe practice that encourages active participation from the client and reduces the workload for the staff by using leverage.

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