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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. "Maintain the client in a supine position for 24 hours following surgery.": Prolonged supine positioning increases the risk of pulmonary complications such as atelectasis. Early mobilization and elevating the head of the bed help promote lung expansion and reduce postoperative risks.

B. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected and may indicate urinary retention, a common complication after anesthesia. The nurse should assess and address it promptly, rather than consider it normal.

C. "Report bleeding that saturates the client's dressing.": Active bleeding that saturates a postoperative dressing may indicate hemorrhage and requires immediate intervention. Reporting this finding is critical to prevent further complications like hypovolemia or shock.

D. "Ensure the client's urinary output is no less than 20 mL per hour.": Urine output should be at least 30 mL per hour in adults. A rate below this may indicate hypoperfusion or renal impairment and should prompt further assessment and intervention.

A. Call in additional medical-surgical unit nursing care staff. B. Act as a liaison between the facility and the media. C. Determine the medical needs of incoming clients through the emergency department. D. Recommend to the provider specific acute care clients for discharge.

Correct Answer is D

Explanation

Rationale:

A. Call in additional medical-surgical unit nursing care staff: The initial priority during a mass casualty event is to maximize available resources and free up beds by discharging stable clients. Staffing adjustments come after determining how to expand capacity.

B. Act as a liaison between the facility and the media: This role falls under the responsibilities of public relations or designated administrative personnel. Nurses should focus on patient care and operational tasks relevant to their scope during a crisis.

C. Determine the medical needs of incoming clients through the emergency department: Triage of incoming casualties is performed by designated emergency department staff. Nurses from other units typically assist by creating space or relocating stable clients.

D. Recommend to the provider specific acute care clients for discharge: Identifying stable clients who can be safely discharged allows beds and resources to be allocated to incoming critical cases. This is an appropriate and immediate nursing response during mass casualty.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

Correct Answer is C

Explanation

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A charge nurse is supervising a newly hired nurse who is instructing a client about how to use a walker. For which of the following actions should the charge nurse intervene?

The nurse reviews the Nurses' Notes from Day 1 at 1100. Exhibits For each potential nursing Intervention, click to specify if the Intervention is anticipated or not anticipated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A nurse is reviewing a client's laboratory values. Which of the following should the nurse review to evaluate the client's nutritional status?

A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?

A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform?

A nurse is preparing to assess a client for pulse deficit. Which of the following actions should the nurse plan to take?