A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take?

Select a vein on the back of the hand.

Clean the site using vigorous friction.

Use a 22-gauge catheter for insertion.

Apply a tourniquet firmly above the insertion site.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Select a vein on the back of the hand: Veins on the dorsum of the hand are often more fragile and prone to infiltration or rupture in older adults. Using a more proximal site, such as the forearm, is generally safer and more stable for IV therapy.

B. Clean the site using vigorous friction: Older adults often have thinner, more delicate skin that can tear easily. While proper antiseptic technique is important, vigorous friction can cause skin trauma and should be avoided during site preparation.

C. Use a 22-gauge catheter for insertion: A 22-gauge catheter is appropriate for older adults because it minimizes vein trauma while still allowing for adequate flow rates. This size is effective for most fluids and medications while reducing the risk of vessel damage.

D. Apply a tourniquet firmly above the insertion site: Applying a tourniquet too tightly can injure fragile veins or cause them to collapse. In older adults, using minimal pressure or alternative vein-dilation methods like warm compresses is often safer.

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Correct Answer is B

Explanation

Rationale:

A. Tenting skin turgor: Tenting indicates dehydration or fluid volume deficit, not overload. It reflects reduced skin elasticity due to poor interstitial fluid volume.

B. Respiratory rate 30/min: Tachypnea can result from pulmonary congestion or edema due to excess fluid in the intravascular space. It is a classic sign of fluid overload as the lungs struggle with impaired gas exchange.

C. Skin warm and dry: Warm, dry skin is a normal finding and does not suggest volume overload. Fluid retention typically causes edema or moist skin in severe cases.

D. Heart rate 60/min: A heart rate within normal range does not point to fluid overload. Often, fluid overload is associated with tachycardia due to increased preload and compensatory responses.

A. "Decrease your intake of cranberry juice." B. "Limit your fluid intake to 500 milliliters per day." C. "Plan to urinate every 3 hours while you are awake." D. "Take your diuretic medication with your evening meal."

Correct Answer is C

Explanation

Rationale:

A. "Decrease your intake of cranberry juice.": Cranberry juice is not known to worsen urge incontinence. It is more commonly used for urinary tract health. There is no need to reduce it unless the client finds it personally irritating.

B. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluids can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence. Adequate hydration is essential for bladder health.

C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding helps retrain the bladder by establishing regular emptying times and reducing urgency. Over time, this improves bladder control and reduces incontinence episodes.

D. "Take your diuretic medication with your evening meal.": Diuretics should be taken in the morning to avoid nocturia and sleep disturbances. Evening dosing increases the risk of nighttime incontinence due to increased urine production during sleep.

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A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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