A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?
Place the tourniquet above the proposed insertion site.
Place the extremity in a dependent position.
Choose the most proximal site on the extremity selected.
Apply a cool compress for several minutes before insertion of the IV catheter.
The Correct Answer is A
Choice A reason:
When preparing to insert an IV catheter, placing the tourniquet above the proposed insertion site helps facilitate venous distension and makes it easier to locate a suitable vein for the catheter insertion. This technique helps to improve visibility and access to the vein.
Choice B reason:
Placing the extremity in a dependent position (lower than the heart) can increase venous pressure and make it more difficult to insert the catheter.
Choice C reason:
Choosing the most proximal site on the extremity is not always necessary or appropriate. Veins distal to the proposed insertion site should be considered first, as they tend to be smaller and less accessible.
Choice D reason:
Applying a cool compress is not typically done before IV catheter insertion. It might cause vasoconstriction and make it more difficult to access a suitable vein.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Obtaining printed information about insulin self-administration is a first recommendation as it can be done after ensuring the client's ability to afford the supplies.
Choice B reason:
Making a copy of the medication reconciliation form for the client is not a first recommendation as it can be done after ensuring the client's access to supplies.
Choice C reason:
Determining whether the client can afford the insulin administration supplies is the first action to be taken. The first step should be to ensure that the client can afford the insulin administration supplies. Proper management of diabetes requires having access to the necessary equipment, including insulin, syringes, pens, or other devices. If the client cannot afford these supplies, alternative options or assistance programs may need to be explored to ensure the client's safety and well-being.
Choice D reason:
Providing the client with the contact number for a diabetes education specialist is important for long-term management, but addressing the affordability of supplies should take precedence initially.
Correct Answer is B
Explanation
Choice A reason:
Performing percussion over the lower back: While percussion is part of the postural drainage technique, the specific areas to be percussed depend on the client's individualized care plan, which is based on the location of lung segments affected by cystic fibrosis. The nurse should follow the care plan and target the appropriate lung segments for percussion.
Choice B reason:
Covering the area of percussion with a towel is correct. When performing postural drainage with percussion and vibration for a client with cystic fibrosis, it is important to cover the area of percussion with a towel. This helps protect the client's skin and prevent discomfort or injury during the procedure. The towel acts as a barrier between the nurse's hand and the client's skin, allowing for effective percussion while minimizing friction and pressure
Choice Creason:
Scheduling postural drainage after meals: Postural drainage is ideally performed before meals or at least 1-2 hours after meals to avoid potential discomfort or vomiting due to the positioning and movement during the procedure.
Choice Dreason:
Instructing the client to exhale quickly during vibration: Vibration is typically performed during the client's exhalation phase, but the instruction should focus on slow, controlled exhalation rather than quick exhalation.
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