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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Hematuria: Blood in the urine can occur with sickle cell disease due to renal papillary necrosis, but it is not specific to acute chest syndrome and does not require immediate emergency action in this context.
B. Sneezing: Sneezing is typically associated with upper respiratory infections or allergies and is not indicative of acute chest syndrome. It is not a critical symptom in this scenario.
C. Substernal retractions: Substernal retractions are a sign of respiratory distress and can indicate acute chest syndrome a life-threatening complication of sickle cell anemia. It involves pulmonary infiltration and can rapidly progress to hypoxia and respiratory failure, requiring urgent intervention.
D. Temperature 37.9° C (100.2° F): While fever in a sickle cell client should be closely monitored and reported, this temperature is low-grade. Alone, it does not immediately signal acute chest syndrome without accompanying respiratory symptoms.
Correct Answer is D
Explanation
Rationale:
A. Misoprostol: Misoprostol is a prostaglandin used to stimulate uterine contractions and control postpartum hemorrhage. It is generally safe for clients with hypertension, as it does not cause significant vasoconstriction or elevate blood pressure.
B. Oxytocin: Oxytocin is commonly used to manage postpartum hemorrhage by inducing uterine contractions. It does not have hypertensive effects and is safe for use in clients with a history of high blood pressure.
C. Terbutaline: Terbutaline is a beta-agonist used for tocolysis, not for treating postpartum hemorrhage. Although it may cause tachycardia and hypotension, it is not a uterotonic and is not relevant in this context.
D. Methylergonovine: Methylergonovine is contraindicated in clients with hypertension because it causes intense vasoconstriction, which can significantly elevate blood pressure and increase the risk of stroke or cardiac events in hypertensive clients.
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