The charge nurse is observing a new nurse who is preparing to insert an intravenous (IV) catheter.
The new nurse has gathered supplies including intravenous catheters, an intravenous insertion kit, and a 4x sterile gauze dressing to cover and secure the insertion.
What action should the charge nurse take?
Verify that the nurse has gathered the necessary supplies.
Advise the nurse to use a transparent dressing over the site.
Ensure the nurse tapes the gauze dressing securely in place.
Intend to inspect the secured IV site after the insertion procedure.
The Correct Answer is B
Choice A rationale
Verifying that the nurse has gathered the necessary supplies is important, but it is not the most critical action in this scenario. The new nurse has already gathered the necessary supplies for the procedure.
Choice B rationale
This is the correct answer. A transparent dressing is preferred over a gauze dressing for securing an IV catheter. It allows for easy inspection of the insertion site for signs of infection.
Choice C rationale
Ensuring that the gauze dressing is taped securely in place is not the most critical action in this scenario. As mentioned, a transparent dressing is generally preferred for securing an IV catheter.
Choice D rationale
While inspecting the secured IV site after the insertion procedure is important, advising the nurse to use a transparent dressing over the site is a more immediate need. This will allow for continuous visual inspection of the site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
Choice A rationale
For a client who has been intubated and is on a ventilator due to sepsis, the most appropriate action based on the client’s status would be to continue weaning the ventilator as ordered.
Weaning is the process of gradually reducing ventilator support, and it is typically initiated once the underlying cause of respiratory failure has been addressed. In this case, if the client’s condition has stabilized and there are no contraindications, continuing the weaning process as ordered would be the most appropriate action.
Choice B rationale
Decreasing the tidal volume is not necessarily the most appropriate action based on the client’s status. Tidal volume is the amount of air that is inhaled or exhaled during normal breathing.
While adjustments to tidal volume may be necessary in some cases, such as if the client is experiencing discomfort or if there are concerns about lung injury, there is no information in the scenario to suggest that a decrease in tidal volume is required at this time.
Choice C rationale
Switching the ventilator to pressure control is not necessarily the most appropriate action based on the client’s status. Pressure control ventilation is a mode of ventilation that can be used in certain situations, such as when there is a need to limit airway pressures. However, there is no information in the scenario to suggest that this change is required at this time.
Choice D rationale
Increasing the fractional concentration of inspired oxygen is not necessarily the most appropriate action based on the client’s status. The fraction of inspired oxygen (FiO2) is the concentration of oxygen in the gas mixture that the client is breathing. While adjustments to FiO2 may be necessary in some cases, such as if the client’s oxygen levels are low, there is no information in the scenario to suggest that an increase in FiO2 is required at this time.
Choice E rationale
Increasing the respiratory rate is not necessarily the most appropriate action based on the client’s status. The respiratory rate is the number of breaths that the client takes per minute, and it can be adjusted on the ventilator to meet the client’s needs. However, there is no information in the scenario to suggest that an increase in the respiratory rate is required at this time.
Choice F rationale
Changing the ventilator settings to continuous positive airway pressure (CPAP) is not necessarily the most appropriate action based on the client’s status. CPAP is a mode of ventilation that can be used in certain situations, such as during the weaning process. However, there is no information in the scenario to suggest that this change is required at this time.
Choice G rationale
Alerting the provider of the blood gas values is not necessarily the most appropriate action based on the client’s status. While it is important to communicate significant changes or concerns to the provider, there is no information in the scenario to suggest that the blood gas values are abnormal or require immediate attention.
Correct Answer is D
Explanation
Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the best method for administering the medication. This would dilute the dextrose, potentially reducing its effectiveness.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the best method for administering the medication. This would significantly dilute the dextrose, potentially reducing its effectiveness.
Choice C rationale
Asking the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the best method for administering the medication. This would not provide the immediate glucose boost needed to counteract insulin shock.
Choice D rationale
Pushing the undiluted dextrose slowly through the currently infusing IV is the best method for administering the medication. This allows for rapid administration of a concentrated glucose solution, which is necessary to quickly raise blood glucose levels in a patient experiencing insulin shock.
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