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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. "I should close all doors and windows on the unit." –
This action is part of the "C" (Confine) step, which should be done before attempting to extinguish the fire.
B. "I should evacuate clients who are in immediate danger." –
Rescuing clients is the first step and should be done immediately.
C. "I should activate the facility's fire alarm system." –
Activating the alarm is the second step after rescuing clients.
D. "I should extinguish small fires if it is safe to do so." –
Extinguishing the fire is the last action in the fire safety protocol and should only be attempted if the fire is small and controllable.

A. A fire extinguisher is kept in the kitchen. B. An electrical ground plug is present. C. The client's oxygen tanks are stored on their side. D. The client's walking cane has a rubber tip.

Correct Answer is C

Explanation

A. A fire extinguisher is kept in the kitchen This is a safe and recommended practice, as the kitchen is a common area where fires may occur.
B. An electrical ground plug is present Ground plugs help prevent electrical shock and ensure safety, so no intervention is needed.
C. The client's oxygen tanks are stored on their side Oxygen tanks should always be stored upright and secured to prevent leaks or potential combustion. Storing them on their side increases the risk of damage to the tank or regulator, which can be hazardous.
D. The client's walking cane has a rubber tip A rubber tip provides stability and prevents slipping, making it a safe practice.

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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?

Nursing Test Bank

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