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:
False imprisonment is the correct answer because it occurs when a person intentionally restricts the freedom of movement of another person without proper consent or legal justification. In this scenario, the AP is threatening to place the client in restraints against their will if they do not comply with bed rest. This action is a violation of the client's rights and constitutes false imprisonment.
Choice B reason:
Defamation of character is incorrect: Defamation involves making false statements about someone that harm their reputation. It doesn't apply to this scenario.
Choice C reason:
Battery is incorrect: Battery involves intentional harmful or offensive physical contact with another person without their consent. There is no indication of physical contact in this situation.
Choice D reason:
Assault is incorrect. Assault refers to the intentional threat or act that causes fear of imminent harmful or offensive contact. While there is a threat implied in this scenario, the threat is of false imprisonment rather than physical harm, making false imprisonment a more accurate description of the tort.
Correct Answer is C
Explanation
Choice A reason:
Protective precautions are not necessary because they (also known as reverse isolation) are used for immunocompromised clients to protect them from potential pathogens carried by healthcare workers or visitors.
Choice B reason:
Droplet precautions are not necessary because they are used for infections spread through larger respiratory droplets, like influenza or pertussis.
Choice C reason:
Airborne precautions should be implemented by the nurse. Tuberculosis (TB) is primarily transmitted through the airborne route, as the bacteria that cause TB can be suspended in the air as tiny particles (droplet nuclei) when an infected person coughs, sneezes, speaks, or sings. These particles can be inhaled by others, leading to the potential transmission of the disease.
Choice D reason:
Contact precautions are not necessary because they are used for infections that are transmitted through direct contact with the client or contaminated surfaces, such as MRSA (Methicillin-resistant Staphylococcus aureus) or C. difficile.
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