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 D
Explanation
I give the client his medications when the wife is grocery shopping. This statement would require the nurse to re-evaluate and correct the plan of care because home health aides are not allowed to administer medications in most states. Home health aides can only provide medication reminders, help put the medication into the hands of the user, or assist with self-administration of certain forms of medications.
Giving medications to the client without supervision or delegation by a registered nurse or physician is a violation of the scope of practice and could harm the client.
Choice A is wrong because removing throw rugs from the client’s walking path is a safety measure that can prevent falls and injuries for a client with Alzheimer’s disease.
Choice B is wrong because documenting activities with the client before leaving for the day is a professional responsibility that ensures continuity of care and accountability.
Choice C is wrong because contacting the nurse if there are any questions about the plan of care is a sign of good communication and collaboration that can enhance the quality of care for the client.
Correct Answer is B
Explanation
I should always have my breakfast ready to eat before injecting my morning insulin. This statement confirms that the client understands the importance of matching insulin administration with food intake to prevent hypoglycemia.
Choice A is wrong because hemoglobin A1C should be checked every 3 months, not monthly, to monitor long-term glycemic control.
Choice C is wrong because eating early and taking extra insulin later can cause fluctuations in blood glucose levels and increase the risk of complications.
Choice D is wrong because on sick days, the client should check blood sugar more
often and eat small amounts of carbohydrates to prevent hyperglycemia and ketoacidosis.
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