A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein?

Dangle the client's arm over the edge of the bed.

Stroke the skin near the vein in an upward direction.

Instruct the client to ﬂex their arm with the hand open.

Apply a cool compress to the vein for 10 min.

Answer and Explanation

The Correct Answer is A

The correct answer is that the nurse should dangle the client's arm over the edge of the bed to help dilate the vein. This technique uses gravity to increase blood ﬂow to the arm and dilate the veins, making it easier to insert a peripheral IV catheter.

Options b, c and d are not eﬀective techniques for dilating a vein for IV insertion. Stroking the skin near the vein in an upward direction, instructing the client to ﬂex their arm with the hand open and applying a cool compress to the vein for 10 min are not eﬀective methods for dilating a vein.

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Correct Answer is ["A","B","D","E"]

Explanation

The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much ﬂuid too quickly during a blood transfusion.

c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a diﬀerent type of transfusion reaction.

A. Encourage the client to take sips of water. B. Check for gastric residual volume. C. Flush the tube with sterile 0.9% sodium chloride irrigation. D. Encourage the client to breathe deeply and cough.

Correct Answer is B

Explanation

Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.

a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.

c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.

d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.

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A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein?

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Naxlex Comprehensive Predictor Exams

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Explanation

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