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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is that the nurse should complete an incident report. An incident report is a formal record of an unexpected event that occurred in a healthcare facility. It is important for the nurse to document the details of the visitor's fall, including the date, time, location and any witnesses. This information can be used to identify and address any safety hazards that may have contributed to the fall.
Options a, c and d are not appropriate actions for the nurse to take in this situation. Administering acetaminophen to the client is not relevant to the visitor's fall. Sending the visitor to the risk management office and documenting the occurrence in the client's medical record are not necessary steps in this situation.
Correct Answer is ["F"]
Explanation
f) Skin surrounding the stoma is reddened and appears irritated.
The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.
Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
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