A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when Initiating IV therapy?
The radial vein on the left wrist
The cephalic vein in the left distal forearm
The cephalic vein on the back of the right hand
The basilic vein in the right antecubital fossa
The Correct Answer is B
When selecting a vein for IV therapy, it is important to consider several factors, including accessibility, integrity, and suitability of the vein. In this case, the client has undergone a right mastectomy, which means the right arm and hand on the affected side might be compromised due to surgery and potential lymphedema. Therefore, it is advisable to avoid using the veins on the affected side.
The cephalic vein in the left distal forearm is a suitable choice because it is on the opposite side of the mastectomy and provides accessibility for venipuncture. It is important to assess the integrity and condition of the vein before insertion to ensure it can accommodate the IV catheter and maintain patency throughout the infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When a client is receiving continuous enteral feedings through a gastrostomy tube, it is important to maintain the patency of the tube and prevent clogging. Flushing the tube with water helps to clear any residue or formula buildup, ensuring the tube remains open and functioning properly. Flushing the tube every 2 hours is a common practice to prevent occlusion.
The tubing set for enteral feedings is usually changed every 24 to 48 hours, depending on the facility's policy. This helps prevent bacterial contamination and maintain the integrity of the system.
Enteral formulas should be administered at room temperature or as prescribed by the healthcare provider. Heating the formula to a specific temperature may alter its composition or cause burns to the client's gastrointestinal tract.
Routine aspiration of residual volume is not necessary for clients receiving continuous enteral feedings. It may be done intermittently or as per the healthcare provider's order to assess gastric residual volume and prevent complications such as aspiration pneumonia, but it is not required every 4 hours for all clients.
Correct Answer is C
Explanation
A potassium level of 5.8 mEq/L is above the normal range (typically 3.5-5.0 mEq/L), indicating hyperkalemia. Hyperkalemia can have serious implications for the client's cardiac function and requires medical intervention. The nurse should notify the healthcare provider promptly so that appropriate actions can be taken to address the high potassium level.
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