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:
A registered dietitian is not appropriate as he or she can provide nutritional assessment and guidance to ensure the client's dietary needs are met.
Choice B reason:
A speech-language pathologist is not appropriate because it is crucial for addressing communication and swallowing difficulties that can arise from a stroke.
Choice C reason:
Occupational therapy is the right choice. Clients who have had a stroke often experience difficulties with activities of daily living (ADLs) due to the physical and cognitive changes that can result from the stroke. Occupational therapists are specialized in helping individuals regain or develop the skills needed to perform daily activities and tasks. They can assist stroke survivors in regaining independence in activities such as dressing, grooming, bathing, and feeding.
Choice D reason:
A physical therapist can assist with mobility and improving physical functioning, but since the question specifically mentions assistance with morning ADLs, the occupational therapist is the most appropriate choice.
Correct Answer is A
Explanation
Choice A reason:
A. Dilated pupils
During the alarm reaction stage of the general adaptation syndrome (GAS), the body's initial response to stress triggers the "fight or flight" response. This response is characterized by the release of stress hormones, increased sympathetic nervous system activity, and various physiological changes to prepare the body to respond to the stressor. Dilated pupils are one of the manifestations of the fight or flight response, allowing for improved visual acuity and awareness of the environment.
Choice B reason:
Physical exhaustion is inappropriate. This is typically associated with the exhaustion stage of GAS, which follows the alarm reaction stage.
Choice C reason:
Bradycardia is inappropriate. Bradycardia (slow heart rate) is not a typical manifestation during the alarm reaction stage. Increased heart rate (tachycardia) is more common during this stage.
Choice D reason:
Depression is inappropriate. Depression is not a direct manifestation of the alarm reaction stage. It is a psychological response that may occur during or after prolonged stress and may be associated with the later stages of GAS.
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