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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "The client's room number and diagnosis are written on the hallway communication board." This is a breach of client confidentiality because it publicly displays protected health information (PHI) where unauthorized individuals, including visitors and non-essential staff, could see it. This violates HIPAA (Health Insurance Portability and Accountability Act) regulations.
B. "The history and physical in the electronic medical record describes the client's previous suicide attempt." The electronic medical record (EMR) is a secure and appropriate place for documenting the client's health history. Access is restricted to healthcare providers involved in the client’s care.
C. "The time when the client can next have pain medication is written on their bedside communication board." This does not violate confidentiality, as it is relevant to the client’s direct care and is visible only to the healthcare team and the client.
D. "The client is wearing a color-coded bracelet that states they are a fall risk." Color-coded bracelets are a standard safety practice in hospitals to communicate important patient care needs to staff. This does not disclose specific medical information beyond the fall risk status.
Correct Answer is C
Explanation
A. Inform the client they cannot refuse the surgery once the consent form has been signed. A client has the right to refuse treatment at any time, even after signing a consent form.
B. Explain the risks of the surgery to the client. The provider is responsible for explaining the risks, benefits, and alternatives of the procedure. The nurse's role is to witness consent and ensure the client understands.
C. Ensure the client has advance directives on file. Since the client has a serious, life-threatening illness (stage 4 cancer) and is undergoing surgery, it is important to verify whether they have advance directives, such as a living will or durable power of attorney for healthcare. These documents ensure that their wishes regarding medical treatment are followed.
D. Ask the client if they wish to be resuscitated in the event they stop breathing. While this is an important conversation, it is typically initiated by the provider. The nurse should confirm whether the client has a Do Not Resuscitate (DNR) order or advance directives in place.
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