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:
The cephalic vein on the back of the right hand is incorrect because it might still involve the same arm as the mastectomy site, and it is important to avoid this side.
Choice B reason:
The radial vein on the left wrist is incorrect because it is not on the opposite side of the mastectomy and could increase the risk of lymphedema.
Choice C reason:
The basilic vein in the right antecubital fossa is the appropriate answer. When inserting an IV catheter for a client who has undergone a right mastectomy, it is generally advisable to avoid the arm on the same side as the mastectomy due to the risk of lymphedema and impaired lymphatic drainage. The basilic vein in the right antecubital fossa (the inner bend of the right elbow) would be a suitable choice in this case, as it is on the opposite side of the mastectomy.
Choice D reason:
The cephalic vein in the left distal forearm is on the same side as the mastectomy and should be avoided to reduce the risk of complications.
Correct Answer is ["A","B","E"]
Explanation
Choice A reason:
Checking medication expiration dates is important to ensure that medications are safe and effective.
Choice B reason:
Having a fire escape plan is crucial in case of emergencies such as fires. It's important for the client and their family to know how to evacuate the home safely.
Choice C reason:
Setting the hot water heater to 140 degrees Fahrenheit is too hot and can lead to scalding. The recommended temperature is typically around 120 degrees Fahrenheit to prevent burns.
Choice D reason:
Applying tape to frayed electrical cords is not a safe practice. Frayed cords should be replaced to avoid electrical hazards.
Choice E reason:
Using grab bars when getting in and out of the bathtub can prevent slips and falls, especially in a potentially slippery environment.
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