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?
Instruct the client to flex their arm with the hand open.
Dangle the client's arm over the edge of the bed.
Apply a cool compress to the vein for 10 min.
Stroke the skin near the vein in an upward direction.
The Correct Answer is B
Dangling the client's arm over the edge of the bed helps dilate the vein by increasing venous pressure due to gravity. Flexing the arm with the hand open does not affect venous dilation and may cause muscle tension that can impede insertion. Applying a cool compress constricts rather than dilates the vein by causing vasoconstriction. Stroking the skin near the vein may irritate or damage the vein and does not promote dilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Place an activated tuning fork in the middle of the client's forehead. The rationale for this answer is that Weber's test is used to assess for conductive or sensorineural hearing loss by comparing bone conduction in both ears. The nurse places an activated tuning fork in the middle of the client's forehead and asks if the sound is heard equally in both ears or louder in one ear.
Correct Answer is A
Explanation
Cheyne-Stokes respirations are an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. This type of breathing may occur in people who are dying due to heart failure, stroke, brain injury or other causes. The nurse should expect to observe irregular respirations with frequent periods of apnea in the client who is dying and having Cheyne-Stokes respirations.
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