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 C

Explanation

The correct answer is choice b. “I can start the medication 30 minutes earlier.”.

Choice A rationale:

Adjusting the time and schedule for convenience is not appropriate for medications like vancomycin, which require precise timing to maintain therapeutic levels and avoid resistance.

Choice B rationale:

Starting the medication 30 minutes earlier is a reasonable adjustment that maintains the medication’s effectiveness and safety.

Choice C rationale:

Administering the medication up to 2 hours after the usual schedule time is incorrect because it could lead to subtherapeutic levels and reduced effectiveness.

Choice D rationale:

Infusing the medication at a faster rate is unsafe as it increases the risk of adverse reactions, such as "red man syndrome".

A. Heart rate 90/min. B. Hematoma over the insertion site. C. Bounding pulses in the affected extremity. D. Report of discomfort at the insertion site continue.

Correct Answer is B

Explanation

A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization.
The nurse should notify the provider immediately if a hematoma is observed.
Choice A is wrong because a heart rate of 90/min is within the normal range for adults and does not indicate a complication.
Choice C is wrong because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
Choice D is wrong because the report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
The nurse can provide pain relief as needed but does not need to notify the provider unless the pain is severe or persistent.
Normal ranges for heart rate are 60-100 beats per minute for adults. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic pressure and 80 mmHg or lower for diastolic pressure. Normal ranges for oxygen saturation are 95-100% for adults.

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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?

Nursing Test Bank

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Correct Answer is C

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