151. A nurse is preparing to remove a peripheral IV for a preschooler. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Inspect the IV catheter tip

Apply firm pressure at the IV site.

Remove the IV catheter while keeping the catheter hub parallel to the insertion site.

Allow the preschooler to assist with removing the transparent dressing over the IV

Turn off the IV infusion pump and damp the y tubing

Answer and Explanation

The Correct Answer is E,D,B,C,A

E: The first step is to turn off the IV infusion pump and clamp the IV tubing to prevent air from entering the line and to stop the flow of medication or fluids.

D: Next, allowing the preschooler to assist with removing the transparent dressing can help in reducing anxiety and providing a sense of control, which is important for a child's emotional well-being during medical procedures.

B: Applying firm pressure at the IV site after the catheter is removed helps to prevent bleeding and ensures the closure of the venipuncture site.

C: Removing the IV catheter while keeping the catheter hub parallel to the insertion site minimizes discomfort and the risk of damaging the vein.

A: Finally, inspecting the IV catheter tip after removal is essential to ensure that the entire catheter has been removed and that no part has been left in the vein.

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Correct Answer is A

Explanation

A. Documenting the client's respiratory rate in 1 hour is within the scope of practice for an assistive personnel (AP) and does not require nursing judgment or assessment.
B. Monitoring the client for an allergic reaction for 30 minutes requires nursing judgment and assessment skills to recognize signs and symptoms of allergic reactions.
C. Checking the client's response to the medication in 1 hour requires nursing judgment and assessment skills to evaluate pain relief and any adverse effects.
D. Evaluating the client for therapeutic effects in 30 minutes requires nursing judgment and assessment skills to determine the effectiveness of the pain medication.

A. The client's most recent blood pressure reading was 110/60 mm Hg. B. The client's morning laboratory results included a potassium level of 4.9 mg/dL. C. The client has 2 pitting edema in the lower extremities. D. The client's partner assisted them with their meal tray.

Correct Answer is C

Explanation

A. While the blood pressure reading provides information about the client's cardiovascular status, it does not specifically indicate the severity of heart failure. Therefore, it is not the most pertinent information to include in the report.
B. The potassium level is important to monitor in clients with heart failure due to the potential for electrolyte imbalances, but a specific potassium level of 4.9 mg/dL may not be immediately relevant to the client's current status. Therefore, it is not the most critical information to include in the report.

C. Pitting edema in the lower extremities is a common finding in clients with heart failure and can indicate fluid overload, a hallmark characteristic of heart failure. Including this information in the report is essential for providing an accurate picture of the client's condition and current status.
D. While assistance with meals may provide insight into the client's functional status and support system, it is not as directly related to the client's heart failure as the presence of pitting edema.

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151. A nurse is preparing to remove a peripheral IV for a preschooler. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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