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","E","F","G"]
Explanation
Rationale:
A. Initiate contact precautions: Endometritis is not typically caused by a pathogen requiring contact precautions (like MRSA or C. difficile). Standard precautions are sufficient unless otherwise indicated.
B. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: The prescribed antibiotics (e.g., clindamycin) are generally considered safe for breastfeeding, and lactation should be encouraged unless specifically contraindicated.
C. Monitor the height and tone of the client's fundus: Fundal tenderness, foul-smelling lochia, and fever are signs of endometritis. Ongoing fundal assessment is important to evaluate uterine involution and identify potential complications like subinvolution or abscess formation.
D. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to relax the uterus in cases of hyperstimulation during labor not for treating uterine infection or postpartum discomfort.
E. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: Culturing lochia helps identify the causative organism of the uterine infection and guide antibiotic therapy. This is a standard step in suspected endometritis cases.
F. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Positioning the client with the head elevated allows for better lochia drainage, preventing accumulation that could worsen infection or discomfort.
G. Instruct the client to wash her hands before and after changing her perineal pad: Good perineal hygiene helps prevent the spread of infection and supports recovery, especially in the context of suspected endometritis.
Correct Answer is A
Explanation
Rationale:
A. "I prefer to leave the lights off when I am changing my clothes.": This statement suggests discomfort with the appearance of the body after surgery and a desire to hide it, which reflects an altered body image. Avoiding visual exposure is a common coping mechanism for those struggling with physical changes.
B. "I am ready to join a breast cancer support group.": Willingness to participate in a support group indicates acceptance and proactive coping. It reflects psychological adaptation rather than body image disturbance.
C. "I want to have reconstructive surgery as soon as I can.": Expressing a desire for reconstruction shows future-oriented thinking and a readiness to restore body image, not necessarily an inability to accept the current state.
D. "I understand that my scars will eventually fade.": This statement demonstrates acceptance and understanding of the healing process, indicating a realistic and healthy perception of body changes.
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