A nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the following actions should the nurse take?
Apply the tourniquet 15 cm (6 in) above the insertion site.
Check for pulsation at sites proximal to the tourniquet.
Anchor the vein by stretching the skin 2.5 cm (1 in) proximal to the insertion site.
Wipe the skin dry before inserting the catheter.
The Correct Answer is C
Choice A reason: Applying the tourniquet 15 cm (6 in) above the insertion site is incorrect. The tourniquet should be applied about 7.5 cm (3 in) above the site to engorge the vein without excessive pressure. Applying it too high reduces effectiveness and increases discomfort.
Choice B reason: Checking for pulsation at sites proximal to the tourniquet is unnecessary and inappropriate. Pulsation indicates an artery, not a vein, and IV catheters should never be inserted into arteries. This step does not belong in IV insertion.
Choice C reason: Anchoring the vein by stretching the skin 2.5 cm (1 in) proximal to the insertion site is correct because it stabilizes the vein, prevents rolling, and facilitates smooth catheter insertion. This technique reduces trauma and increases success rates.
Choice D reason: Wiping the skin dry before inserting the catheter is incorrect. The skin should be cleansed with antiseptic and allowed to air dry completely to reduce infection risk. Wiping it dry compromises sterility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Checking the skin after 15 minutes is appropriate to prevent tissue injury such as frostbite. Ice therapy should be monitored closely to ensure safety and effectiveness.
Choice B reason: Applying ice directly to the skin is unsafe because it can cause frostbite and tissue damage. Ice should always be wrapped in a barrier such as a towel.
Choice C reason: Ice therapy decreases blood flow by causing vasoconstriction, which reduces swelling and inflammation. Saying it increases blood flow is incorrect.
Choice D reason: Heat therapy should not immediately follow ice therapy. Heat increases blood flow and swelling, which is contraindicated in the acute phase of injury.
Correct Answer is B
Explanation
Choice A reason: Fluticasone is an inhaled corticosteroid used for long-term control of asthma. It is not required to be administered before other inhaled medications; bronchodilators are usually given first to open airways before corticosteroids.
Choice B reason: Rinsing the mouth and gargling after each use is correct because inhaled corticosteroids can cause oral candidiasis (thrush). Rinsing removes residual medication and reduces this risk.
Choice C reason: Fluticasone is not used as needed; it is a maintenance medication taken regularly to prevent inflammation. Rescue inhalers such as albuterol are used for acute symptom control.
Choice D reason: Growth may be slowed, not accelerated, in children using inhaled corticosteroids. Monitoring growth is important during long-term therapy.
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