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 C
Explanation
The client's emotional response is a normal reaction to the surgery and may be related to changes in her body image and self-esteem. By acknowledging the client's feelings, the nurse can establish a trusting relationship and help the client to cope with her situation. Encouraging the client to assist with her dressing changes or providing her with a mirror may be appropriate interventions later, but the nurse should address the client's emotional needs first. Referring the client to a breast cancer support group may also be appropriate, but this should be done in collaboration with the client after assessing her readiness and willingness to participate.
Correct Answer is ["440"]
Explanation
To calculate the client's net fluid intake, we need to subtract the output (emesis and urine) from
the intake (IV infusion and IV bolus). Intake:
- 0.9% sodium chloride IV infusion: 600 mL
- Cefazolin in dextrose 5% in water IV bolus: 100 mL Output:
- Emesis: 200 mL
- Voided urine: 40 mL
- Urine from straight catheterization: 20 mL Net fluid intake = Intake - Output
Net fluid intake = (600 mL + 100 mL) - (200 mL + 40 mL + 20 mL) Net fluid intake = 700 mL - 260 mL
Net fluid intake = 440 mL
Therefore, the nurse should record the client's net fluid intake as 440 mL.
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