A nurse is caring for a client who has a prescription for parenteral therapy. Which of the following actions should the nurse take when initiating IV therapy?
Insert the IV catheter using the Z-track technique.
Insert the IV catheter with the bevel down.
Remove the roller clamp from the tubing prior to IV insertion.
Apply the tourniquet 5 to 10 cm (about 2 to 4 in) above the IV insertion site.
The Correct Answer is D
A. "Insert the IV catheter using the Z-track technique." The Z-track technique is used for intramuscular (IM) injections, not IV therapy.
B. "Insert the IV catheter with the bevel down." The bevel should be up to facilitate smooth vein entry.
C. "Remove the roller clamp from the tubing prior to IV insertion." The roller clamp should remain in place to control fluid flow and prevent air from entering the tubing.
D. "Apply the tourniquet 5 to 10 cm (about 2 to 4 in) above the IV insertion site." This placement helps distend the vein for easier cannulation without restricting arterial blood flow.
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Related Questions
Correct Answer is D
Explanation
A. A community health nurse can provide education, medication management, and health monitoring, but they do not specifically focus on ADL assistance.
B. Respite care provides temporary relief for caregivers, but it does not directly help the client develop skills to maintain independence.
C. A dietitian focuses on nutritional needs and meal planning, but this does not directly address the increased difficulty with ADLs.
Correct Answer is C
Explanation
A. Report the incident to the pharmacy. While the pharmacy may need to be informed, client safety is the priority. The immediate concern is monitoring the client for opioid overdose effects.
B. Notify the client's provider. The provider should be notified, but assessing the client's condition comes first so that the nurse can provide accurate information about any potential adverse effects.
C. Measure the client's respiratory rate. The priority action is to assess the client for signs of opioid toxicity, especially respiratory depression. Morphine can cause decreased respiratory rate, sedation, and hypotension. If the respiratory rate is dangerously low (e.g., below 12 breaths per minute), interventions such as administering naloxone (Narcan) may be necessary.
D. Complete an incident report. An incident report should be completed, but client safety and assessment take priority before documentation.
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