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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?

A.

Select a site on the client’s dominant arm

B.

Apply a tourniquet below the venipuncture site

C.

Elevate the client’s arm prior to insertion

D.

Choose a vein that is palpable and straight

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. The nurse should choose a vein that is palpable and straight for IV catheter insertion.

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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Related Questions

Correct Answer is C

Explanation

The correct answer is choice C. The nurse should ask the client what the voices are telling them, because this can help assess the client’s risk for harm to self or others, and also show empathy and respect for the client’s experience.

The nurse should not assume that the client’s hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental (choice A).

The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time (choice B).

The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation (choice D).

The nurse should use therapeutic communication techniques to establish rapport and safety with the client who has schizophrenia.

Correct Answer is A

Explanation

The correct answer is A. I can lift objects that are less than 10 pounds.

Here's a breakdown of why the other options are incorrect:

  • B. I can resume activities, such as sewing. - Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
  • C. I can go jogging after 2 weeks. - Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
  • D. I should bend at the waist when putting on my shoes. - Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.

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