The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. Which action should the charge nurse take?
Plan to observe the secured IV site after the insertion procedure.
Remind the nurse to tape the gauze dressing securely in place.
Confirm that the nurse has gathered the necessary supplies.
Instruct the nurse to use a transparent dressing over the site.
The Correct Answer is D
A. Plan to observe the secured IV site after the insertion procedure.
This is a proactive step, but it does not address the immediate need to correct the new nurse’s choice of dressing.
B. Remind the nurse to tape the gauze dressing securely in place.
While securing the dressing is important, it is not the best practice to use a gauze dressing for IV sites as it obscures the view of the insertion site.
C. Confirm that the nurse has gathered the necessary supplies.
Confirming supplies is important, but this does not address the incorrect dressing choice.
D. Instruct the nurse to use a transparent dressing over the site.
This is the correct answer because a transparent dressing allows for continuous visual inspection of the IV site for signs of infection or infiltration, which is crucial for patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The neck is the correct location for auscultating a carotid bruit. A carotid bruit is an abnormal sound heard over the carotid artery in the neck, typically indicative of turbulent blood flow due to a narrowing or blockage in the artery.
B. Auscultating the femoral region would not yield information about carotid bruits. The femoral region pertains to the upper thigh area and is not anatomically related to the carotid artery.
C. The cubital fossa is the inner elbow region and is not associated with auscultation for carotid bruits. It is typically used for auscultation of blood pressure using the brachial artery.
D. The navel (belly button) is not a relevant location for auscultation for carotid bruits. It is far from the carotid arteries and would not provide any meaningful information about carotid artery sounds.
Correct Answer is B
Explanation
A. Respiratory acidosis. Respiratory acidosis occurs when there is hypoventilation, leading to an accumulation of carbon dioxide and increased acidity in the blood. Hyperventilation, as described in the scenario, would not lead to respiratory acidosis.
B. Respiratory alkalosis. Hyperventilation leads to respiratory alkalosis by blowing off excessive carbon dioxide, resulting in decreased levels of carbonic acid and increased blood pH.
C. Metabolic acidosis. Metabolic acidosis results from an accumulation of acids or loss of bicarbonate ions. The scenario does not indicate factors leading to metabolic acidosis.
D. Metabolic alkalosis. Metabolic alkalosis occurs due to excessive loss of acids or increased bicarbonate levels, neither of which is suggested in the scenario.
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