A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

Select a site on the client’s dominant arm.

Apply a tourniquet below the venipuncture site.

Elevate the client’s arm prior to insertion.

Choose a vein that is palpable and straight.

Answer and Explanation

The Correct Answer is D

This will facilitate the insertion of the catheter and reduce the risk of complications such as infiltration, phlebitis, or hematoma. A straight vein will also allow the catheter to be inserted up to the hub, which reduces the risk of contamination along the length of the catheter.

Choice A is wrong because selecting a site on the client’s dominant arm can interfere with the client’s mobility and increase the risk of dislodging the catheter. The nurse should choose a site on the client’s non-dominant arm, preferably on the hand or forearm.

Choice B is wrong because applying a tourniquet below the venipuncture site will impede blood flow and make it harder to locate a suitable vein. The nurse should apply a tourniquet above the venipuncture site, about 10 to 15 cm from the insertion site.

Choice C is wrong because elevating the client’s arm prior to insertion will decrease venous filling and make it harder to palpate a vein. The nurse should lower the client’s arm below the level of the heart to increase venous distension.

Normal ranges for IV catheter size and insertion angle depend on several factors, such as the type and duration of therapy, the condition and size of the vein, and the age and preference of the client.

In general, smaller gauge catheters (20 to 24) are preferred for peripheral IV therapy, and larger gauge catheters (14 to 18) are used for rapid fluid administration or blood transfusion. The insertion angle can vary from 10 to 30 degrees, depending on the depth and location of the vein.

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Correct Answer is B

Explanation

The correct answer is choice b. Remove the device from the room.

Choice A rationale:

Reporting the defect to the equipment maintenance staff is important, but the immediate priority is to ensure the client’s safety by removing the faulty device.

Choice B rationale:

Removing the device from the room is the first action to take to prevent any potential electrical hazards or injuries to the client.

Choice C rationale:

Initiating a requisition for a replacement CPM device is necessary but should be done after the faulty device has been removed to ensure safety.

Choice D rationale:

Ensuring the device inspection sticker is current is part of routine checks, but it does not address the immediate safety concern posed by the frayed cord.

A. Replace the NG tube. B. Provide oral hygiene care. C. Administer an antiemetic medication. D. Evaluate functioning of the suction device.

Correct Answer is D

Explanation

This is because the first priority for the nurse is to assess the cause of the vomiting and ensure that the NG tube is working properly. If the suction device is malfunctioning, it could lead to gastric distension, nausea and vomiting. The nurse should check the suction settings, tubing, canister and connections for any problems.

Choice A is wrong because replacing the NG tube is not the first action to take.

The nurse should first rule out other causes of vomiting before attempting to reinsert the tube, which could be uncomfortable and risky for the client.

Choice B is wrong because providing oral hygiene care is not the most urgent action to take.

While oral hygiene care is important for comfort and infection prevention, it does not address the underlying cause of vomiting or prevent further complications.

Choice C is wrong because administering an antiemetic medication is not the most appropriate action to take.

The nurse should first identify the cause of vomiting and correct it if possible.

Giving an antiemetic medication without resolving the problem could mask symptoms and delay treatment.

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A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

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