A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids.
Which of the following actions should the nurse take?

Initiate IV access on the palmar side of the client's wrist.

Insert a larger gauge IV catheter to prevent phlebitis.

Choose the client's dominant arm for IV access whenever possible.

Select a site proximal to previous venipuncture sites.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Initiating IV access on the palmar side of the client's wrist is not recommended. This area has many delicate structures and is prone to complications such as nerve damage. Choosing a safer, larger vein proximal to the wrist is a better practice.

Choice B rationale:

Inserting a larger gauge IV catheter is not necessary unless the client's condition or prescribed therapy specifically requires it. Using an unnecessarily large catheter can cause discomfort and increase the risk of complications, such as phlebitis.

Choice C rationale:

Choosing the client's dominant arm for IV access whenever possible is not a universally appropriate guideline. The choice of the arm should depend on the condition of the veins and the individual patient's circumstances. The nurse should assess both arms and choose the one with the most suitable and accessible veins.

Choice D rationale:

Selecting a site proximal to previous venipuncture sites is the correct action. Repeated venipuncture in the same area can cause phlebitis and compromise the integrity of the veins. Selecting a new site proximal to previous punctures helps to preserve vein health and reduce the risk of complications.

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Correct Answer is C

Explanation

Choice A rationale:

Measuring the amount of time the child can hear the sound is not the correct action when performing Weber's test. Weber's test is used to assess hearing acuity and lateralization. In this test, a vibrating tuning fork is placed in the middle of the patient's forehead, and the patient is asked if the sound is heard equally in both ears or if it is louder in one ear. This helps identify whether there is a conductive or sensorineural hearing loss. The duration of hearing the sound is not relevant to this test.

Choice B rationale:

Obtaining a tympanogram reading is not necessary before initiating Weber's test. Tympanometry assesses the movement of the eardrum in response to changes in air pressure and can help diagnose conditions like middle ear effusion or eustachian tube dysfunction. However, Weber's test focuses on lateralization of sound and does not require tympanogram readings.

Choice C rationale:

Placing a vibrating tuning fork on the top of the child's head is the correct action for performing Weber's test. By doing so, the nurse can assess whether the sound is perceived equally in both ears or if it is lateralized to one ear. If the sound is lateralized, it can provide valuable information about the type of hearing loss the child may have, whether it's conductive or sensorineural.

Choice D rationale:

Holding a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears is not the correct technique for Weber's test. Placing the tuning fork directly on the patient's forehead is essential for accurate assessment. Holding it close to the ears can lead to misinterpretation of the test results.

A. Weight B. Neuro status C. Auditory hallucinations D. Speech E. Restlessness

Correct Answer is ["B","C","E"]

Explanation

The correct answer is B, C, and E.

A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.

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A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids.
Which of the following actions should the nurse take?