A client with difficult venous access has an intravenous insertion site located at the bend of the wrist.
Which action would be most appropriate for a nurse to take?

Place the arm across the client’s chest to support the wrist.

Use a wrist restraint to decrease mobility in the arm.

Apply an arm board to immobilize the wrist.

Instruct client to limit use of that arm.

Answer and Explanation

The Correct Answer is C

This is because immobilizing the wrist prevents kinking or dislodgement of the intravenous catheter and reduces the risk of complications such as infiltration, phlebitis, or infection.

Some additional information for the response are:

Choice A is wrong because placing the arm across the client’s chest may compromise venous return and increase the risk of thrombosis.

Choice B is wrong because using a wrist restraint may cause skin breakdown, nerve damage, or impaired circulation.

Choice D is wrong because instructing the client to limit use the of that arm may not be sufficient to prevent catheter movement or accidental removal.

Normal ranges for venous access depend on the type and location of the catheter, but some general values are: potassium (3 to 5 mEq/L), blood urea nitrogen (10 to 20 mg/dL), and central venous pressure (8 to 12 mmHg).

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Correct Answer is A

Explanation

“Have you had thoughts about killing yourself?” This is the best response because it directly assesses the client’s suicidal risk and shows empathy and concern.

The other choices are wrong because:

Choice B. “What can’t you go on anymore?” This is a vague and open-ended question that does not address the client’s immediate safety or emotional state.

Choice C. “Don’t think like that.

It’s not true!” This is a dismissive and invalidating response that does not acknowledge the client’s feelings or offer support.

Choice D. “Have you talked to your doctor about these feelings?” This is a deferring and avoiding response that does not explore the client’s situation or provide any intervention.

A. Inspection of lips and mucous membranes. B. Pinches the skin on back of the hand. C. Measures pulse and blood pressure. D. Obtains client's daily weight. E. Palpates scalp and hair distribution.

Correct Answer is ["A","B","C","D"]

Explanation

The correct answers are Choices A, B, C, and D.Choice A rationale:Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale:Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale:Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale:Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale:Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.

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A client with difficult venous access has an intravenous insertion site located at the bend of the wrist. Which action would be most appropriate for a nurse to take?

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Naxlex Comprehensive Predictor Exams

The client states “I can’t go on anymore. Life sucks and the world would be better off without me.” What is the RN’s best response?

Correct Answer is A

Explanation

The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

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A client with difficult venous access has an intravenous insertion site located at the bend of the wrist.
Which action would be most appropriate for a nurse to take?