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

Choose a vein that is palpable and straight.

Select a site on the client's dominant arm.

Apply a tourniquet below the venipuncture site.

Elevate the client's arm prior to insertion.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Choosing a palpable and straight vein is essential for a successful IV insertion. A vein that is easily palpable and visible helps ensure that the catheter can be inserted smoothly, reducing the risk of complications such as infiltration or extravasation. Additionally, selecting a straight vein makes the insertion process easier and less painful for the client.

Choice B rationale:

Selecting a site on the client's dominant arm is not a requirement for IV insertion. The choice of arm depends on the individual client's condition, vein accessibility, and the healthcare provider's preference. Both arms can be used for IV insertion based on the client's specific needs.

Choice C rationale:

Applying a tourniquet below the venipuncture site helps distend the veins, making them more visible and accessible. This technique can aid in locating suitable veins for insertion. However, it is crucial to release the tourniquet once the vein is accessed to prevent complications such as thrombosis or hematoma.

Choice D rationale:

Elevating the client's arm prior to insertion can cause veins to collapse, making it more challenging to insert the IV catheter. Gravity can assist in distending the veins, so the arm should be positioned at or slightly below the level of the heart during IV insertion to maintain adequate blood flow.

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Correct Answer is B

Explanation

The correct answer is Choice B: "When using implanted contraceptive methods, condoms should also be used to protect against STDs."

Choice B rationale: While implanted contraceptive methods are highly effective in preventing unintended pregnancies, they do not provide protection against sexually transmitted diseases (STDs). Therefore, using condoms in conjunction with implanted contraceptives can enhance overall sexual health by reducing the risk of contracting or transmitting STDs. This statement highlights the nurse's understanding of the importance of comprehensive sexual health practices and the limitations of various contraceptive methods.

Choice A rationale: The use of petroleum-based lubricants with condoms can actually compromise their effectiveness. Petroleum-based lubricants can degrade latex condoms, increasing the likelihood of condom breakage or slippage, which in turn raises the risk of both pregnancy and STD transmission.

Choice C rationale: Condoms are indeed effective in preventing pregnancy, but their effectiveness can be enhanced by using them in conjunction with vaginal spermicides. Spermicides containing nonoxynol-9 can provide additional protection by inactivating or killing sperm, thus reducing the risk of pregnancy.

Choice D rationale: Ensuring a proper fit is crucial for a condom's effectiveness, but the statement only emphasizes the condom fitting snugly over the tip of the penis. For optimal protection, a condom should be unrolled to cover the entire erect penis, leaving a small empty space at the tip for semen collection. A condom that is not unrolled completely may be more likely to slip off or break during intercourse.

A. Wash the penis from the scrotum to the tip using a spiral motion. B. Use water with no soap to prevent skin irritation. C. Don sterile gloves to prevent infection. D. Discard the washcloth after cleansing the urethral meatus.

Correct Answer is D

Explanation

The correct answer is choice d.

Choice A rationale:

Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.

Choice B rationale:

Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.

Choice C rationale:

While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.

Choice D rationale:

Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.

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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?