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.
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
Olanzapine is an antipsychotic drug that can cause weight gain and increased blood sugar as common side effects.
Therefore, the nurse should monitor the client’s weight and blood sugar regularly to prevent complications such as obesity and diabetes.
Choice B is wrong because olanzapine does not affect skin turgor, which is a measure of hydration status.
Choice C is wrong because olanzapine does not cause falls, although it may cause dizziness or unsteadiness as side effect.
Choice D is wrong because olanzapine does not cause significant changes in blood pressure, although it may cause orthostatic hypotension (a drop in blood pressure when standing up) as a side effect.
Correct Answer is A
Explanation
This is because aspirin can cause gastrointestinal bleeding, ulceration, and perforation as side effects. Tarry-colored stools indicate the presence of blood in the stool, which is a sign of bleeding in the upper gastrointestinal tract.
This is a serious condition that requires immediate medical attention.
Choice B. Swelling of the leg and knee is wrong because it is not related to aspirin use.
It may indicate inflammation, infection, or injury of the leg and knee, but it is not a priority symptom to report to the HCP.
Choice C. Right upper quadrant discomfort is wrong because it is not related to aspirin use.
It may indicate liver or gallbladder problems, but it is not a priority symptom to report to the HCP.
Choice D. Bruising around the injured knee is wrong because it is not related to aspirin use.
It may indicate trauma, bleeding disorders, or coagulation problems, but it is not a priority symptom to report to the HCP.
Normal ranges for bleeding time are 2 to 7 minutes. Normal ranges for PTT are 25 to 35 seconds. Normal ranges for liver enzymes are AST 10 to 40 U/L and ALT 7 to 56 U/L.
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