A nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the following actions should the nurse take?
Apply the tourniquet 15 cm (6 in) above the insertion site.
Check for pulsation at sites proximal to the tourniquet.
Anchor the vein by stretching the skin 2.5 cm (1 in) proximal to the insertion site.
Wipe the skin dry before inserting the catheter.
The Correct Answer is C
Choice A reason: Applying the tourniquet 15 cm (6 in) above the insertion site is incorrect. The tourniquet should be applied about 7.5 cm (3 in) above the site to engorge the vein without excessive pressure. Applying it too high reduces effectiveness and increases discomfort.
Choice B reason: Checking for pulsation at sites proximal to the tourniquet is unnecessary and inappropriate. Pulsation indicates an artery, not a vein, and IV catheters should never be inserted into arteries. This step does not belong in IV insertion.
Choice C reason: Anchoring the vein by stretching the skin 2.5 cm (1 in) proximal to the insertion site is correct because it stabilizes the vein, prevents rolling, and facilitates smooth catheter insertion. This technique reduces trauma and increases success rates.
Choice D reason: Wiping the skin dry before inserting the catheter is incorrect. The skin should be cleansed with antiseptic and allowed to air dry completely to reduce infection risk. Wiping it dry compromises sterility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Mouthwash often contains alcohol, which can trigger a severe disulfiram reaction. Advising its use is unsafe. Clients should avoid alcohol-containing products such as mouthwash, cough syrups, and certain foods.
Choice B reason: Cologne and antiperspirants may contain alcohol, and substituting one for the other does not eliminate risk. This advice is misleading and unsafe.
Choice C reason: Carrying an identification card is correct because it alerts healthcare providers and others that the client is taking disulfiram. This is important in emergencies to prevent accidental alcohol administration and to explain potential reactions.
Choice D reason: Alcohol consumption should not be limited—it must be completely avoided. Even small amounts can cause severe reactions including hypotension, tachycardia, nausea, and potentially life-threatening complications.
Correct Answer is C
Explanation
Choice A reason: Hydrogen peroxide has limited effectiveness against bloodborne pathogens and is not the recommended agent for cleaning blood-contaminated surfaces. It may disinfect minor wounds but is not suitable for environmental cleaning of biohazard spills.
Choice B reason: Isopropyl alcohol is effective against many bacteria and viruses but is not recommended for cleaning large blood spills. Alcohol evaporates quickly and does not reliably inactivate all bloodborne pathogens such as hepatitis B or HIV when used on contaminated surfaces.
Choice C reason: Chlorine bleach is the recommended agent for cleaning surfaces contaminated with blood. A diluted bleach solution (usually 1:10 ratio) effectively kills bloodborne pathogens, including hepatitis B, hepatitis C, and HIV. It is widely used in healthcare settings for environmental decontamination.
Choice D reason: Chlorhexidine is an antiseptic used for skin preparation and wound cleansing. It is not appropriate for cleaning environmental surfaces contaminated with blood. Its use is limited to patient care, not environmental disinfection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.