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

This is because a normal FHR baseline is between 110 and 160 bpm, and anything above or below this range indicates fetal distress and should be reported to the provider. An FHR baseline of 170/min could indicate fetal tachycardia, which could be caused by maternal fever, infection, dehydration, fetal anemia, or fetal hypoxia.
Choice A is wrong because early decelerations in the FHR are normal and benign, and indicate head compression during contractions.
They do not require any intervention or reporting.
Choice B is wrong because contractions lasting 80 seconds are within the normal range for active labor, which is 40 to 90 seconds per contraction.
They do not indicate any complication or abnormality.
Choice D is wrong because a temperature of 37.4° C (99.3° F) is slightly elevated but not considered a fever. A fever is defined as a temperature of 38° C (100.4° F) or higher.
A mild increase in temperature could be due to dehydration, exertion, or environmental factors, and does not necessarily indicate infection or inflammation.

A. Heart rate. B. Current medications. C. Blood pressure. D. Stool results. E. Respiratory rate. F. WBC count. G. Temperature. H. Hemoglobin and hematocrit.

Correct Answer is ["A","B","C","D","H"]

Explanation

A. Heart rate: The client’s heart rate is elevated at 118/min, which could indicate blood loss, dehydration, pain, anxiety, or infection. This finding requires immediate follow-up to assess the cause and intervene as needed.
B. Current medications: The client is taking ibuprofen 800 mg three times daily PRN for arthritis pain. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastric irritation, ulceration, and bleeding. This finding requires immediate follow-up to evaluate the client’s pain level, medication use, and possible alternatives to NSAIDs.
C. Blood pressure: The client’s blood pressure is low at 90/50 mm Hg, which could indicate hypovolemia, shock, or cardiac dysfunction. This finding requires immediate follow-up to monitor the client’s fluid status, perfusion, and organ function.
D. Stool results: The client’s stool tested positive for occult blood and H. pylori bacteria. Occult blood indicates gastrointestinal bleeding, which could be related to the client’s abdominal pain and weight loss. H. pylori is a common cause of peptic ulcer disease, which can also cause bleeding and pain. This finding requires immediate follow-up to confirm the diagnosis and initiate treatment with antibiotics and acid-suppressing drugs.

H. Hemoglobin and hematocrit: The client’s hemoglobin and hematocrit are low at 9.1 g/dL and 27%, respectively. These values indicate anemia, which could be caused by chronic blood loss, nutritional deficiency, or bone marrow suppression. This finding requires immediate follow-up to determine the etiology and severity of the anemia and provide appropriate therapy such as blood transfusion, iron supplementation, or erythropoietin.

The other findings are not as urgent as the ones above:

E. Respiratory rate: The client’s respiratory rate is normal at 18/min. There is no evidence of respiratory distress or hypoxia.
F. WBC count: The client’s WBC count is normal at 6,700/mm3. There is no indication of infection or inflammation.
G. Temperature: The client’s temperature is slightly elevated at 37.5° C (99.5° F), but not enough to warrant immediate concern. It could be due to stress, dehydration, or a mild infection. The nurse should monitor the temperature trend and report any significant changes or signs of sepsis.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is caring for a client who is admitted to the medical-surgical unit The clientreports, "I'm bloated and my stomach hurts." Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["A","B","C","D","H"]

Explanation

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