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A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Apply pressure to the venipuncture site with sterile gauze.

Perform hand hygiene.

Clamp the IV tubing.

Withdraw the catheter from the client's vein.

Remove the dressing and tape from the venipuncture site.

Answer and Explanation

The Correct Answer is B,E,C,A,D

Correct order:

Perform hand hygiene.
Remove the dressing and tape from the venipuncture site.
Clamp the IV tubing.
Apply pressure to the venipuncture site with sterile gauze.
Withdraw the catheter from the client's vein.

Rationale:

Hand hygiene is the first step to prevent infection before touching any equipment or the client.
Removing the dressing and tape is done after hand hygiene to expose the IV insertion site, preparing it for removal.
Clamping the IV tubing helps stop the infusion and prevents blood from flowing out when the catheter is removed.
Applying pressure with sterile gauze helps to prevent bleeding and hematoma formation after the catheter is removed.
Withdrawing the catheter should be the final step to complete the procedure.

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Correct Answer is B

Explanation

A. Administer a glycerin suppository: While this may help, addressing bowel hypoactivity through ambulation is less invasive and more appropriate initially.
B. Ambulate the client in the hallway. Ambulation stimulates peristalsis, which can help resolve hypoactive bowel sounds and abdominal discomfort, making it the priority action.
C. Request the client to be NPO: Making the client NPO might be necessary later if symptoms worsen or there is suspicion of ileus or obstruction, but it is not the first action.
D. Offer an analgesic medication: Pain relief is essential, but analgesics (especially opioids) can worsen bowel hypoactivity. Prioritize interventions that restore bowel function first.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

The first action the nurse should take is to assess neurovascular status followed by notify the provider.

Assess neurovascular status first: The diminished pulses and coolness of the right foot indicate compromised circulation, requiring immediate evaluation to confirm the severity.
Notify the provider: Once the critical assessment findings are confirmed, notifying the provider for prompt intervention is essential to prevent further complications.

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A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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