A client is prescribed to receive IV therapy and had a mastectomy three years prior. What should the nurse do?

Choice A reason: Marking the time strip on the IV bag helps track infusion duration but is not the priority before administration. Ensuring bag integrity prevents contamination or leakage, which could introduce pathogens or cause fluid loss, compromising patient safety and treatment efficacy.
Choice B reason: Checking the IV bag’s integrity ensures it is free from leaks, cracks, or contamination. A compromised bag can introduce bacteria or air into the bloodstream, leading to infections or embolisms. This step is critical for patient safety before initiating infusion.
Choice C reason: Selecting a vented administration set depends on the fluid type and container. While important, it is secondary to ensuring the bag’s integrity, as a damaged bag could lead to contamination or improper fluid delivery, posing immediate risks to the patient.
Choice D reason: Calculating tonicity is unnecessary, as IV fluids are pre-formulated with known tonicity (e.g., isotonic, hypotonic). The nurse’s priority is ensuring the bag is intact to prevent contamination or fluid loss, which directly impacts patient safety and treatment effectiveness.

Choice A reason: Vein distension under the needle may indicate improper placement or infiltration, not successful cannulation. Advancing the catheter without blood return risks extravasation, causing tissue damage or therapy failure.
Choice B reason: Lack of discomfort is not a reliable indicator of proper catheter placement. Patients may not feel pain despite incorrect positioning. Blood return confirms venous access, ensuring safe advancement of the catheter.
Choice C reason: Easy catheter advancement may occur but does not confirm venous placement. Without blood return, the catheter may be in tissue, risking infiltration. Blood return is the definitive sign for safe advancement.
Choice D reason: Blood return in the backflash chamber indicates the catheter is in the vein, confirming successful cannulation. This allows safe advancement, ensuring proper IV therapy delivery without risking extravasation or tissue damage.