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 A
Explanation
Choice A reason
The client has an implanted defibrillator is the correct answer. Magnet therapy involves the use of magnets to alleviate pain and promote healing. However, it is contraindicated for individuals with implanted electronic devices, such as pacemakers or defibrillators, as the magnetic field could potentially interfere with the functioning of these devices. The safety of using magnet therapy with implanted devices has not been established, and caution is advised.
Choice B reason:
Allergic to penicillin is incorrect. Allergies to penicillin or other substances are not related to the use of magnet therapy.
Choice C reason:
The history of alcohol use disorder is incorrect. A history of alcohol use disorder does not directly contraindicate the use of magnet therapy.
Choice D reason:
The prescription for metoprolol is incorrect. Metoprolol is a common medication used to treat various conditions, including hypertension and certain heart conditions. It is not a contraindication for magnet therapy.
Correct Answer is A
Explanation
Choice A reason:
"New dressing applied as prescribed; no drainage on old dressing. “This entry provides clear and concise information about the action taken (applying a new dressing as prescribed) and the assessment of the old dressing (no drainage present). It accurately reflects the dressing change process and the status of the wound.
Choice B reason:
"Client premedicated with MSO, sub-prior to dressing change." This entry is incorrect because it provides information about the client being premedicated, but it doesn't specifically address the dressing change or the pressure injury.
Choice C reason:
"The wound seems clean and does not appear to be infected." While this entry provides an assessment of the wound's cleanliness and potential infection, it lacks specific details about the dressing change itself.
Choice D reason:
"No changes noted to the wound from previous nursing notes." This entry focuses on comparing the wound to previous notes but doesn't provide information about the current dressing change or assessment.
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