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A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Apply pressure to the venipuncture site with sterile gauze.

Perform hand hygiene.

Clamp the IV tubing.

Withdraw the catheter from the client's vein.

Remove the dressing and tape from the venipuncture site.

Answer and Explanation

The Correct Answer is B,E,C,A,D

Correct order:

Perform hand hygiene.
Remove the dressing and tape from the venipuncture site.
Clamp the IV tubing.
Apply pressure to the venipuncture site with sterile gauze.
Withdraw the catheter from the client's vein.

Rationale:

Hand hygiene is the first step to prevent infection before touching any equipment or the client.
Removing the dressing and tape is done after hand hygiene to expose the IV insertion site, preparing it for removal.
Clamping the IV tubing helps stop the infusion and prevents blood from flowing out when the catheter is removed.
Applying pressure with sterile gauze helps to prevent bleeding and hematoma formation after the catheter is removed.
Withdrawing the catheter should be the final step to complete the procedure.

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Correct Answer is A

Explanation

A. Initiate fall precautions: Fall precautions are essential for clients with aspiration pneumonia and hypoxia as they may be disoriented or have impaired oxygenation, increasing the risk of falls.
B. Applying petroleum jelly to the client's nares is not appropriate in this case, as it does not address the client's aspiration pneumonia or hypoxia.
C. Implementing contact precautions is not necessary for aspiration pneumonia unless there is a specific infection that requires isolation precautions (e.g., bacterial infections).
D. Maintaining the client in a supine position can worsen hypoxia and aspiration, as it can facilitate fluid or food moving into the lungs. The client should be maintained in an upright position to promote better oxygenation and prevent aspiration.

A. The client arouses easily but quickly falls back asleep. B. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr. C. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr. D. The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.

Correct Answer is A

Explanation

A. The client arouses easily but quickly falls back asleep. This could indicate a potential complication, such as a postoperative haemorrhage, hypovolemia which can lead to decreased perfusion and oxygenation.
B. 20 mL of dark red drainage over 4 hours: This is expected postoperative output.
C. 60 mL of dark yellow urine over 4 hours: This is a low output but not immediately critical compared to potential hypoxia.
D. Pain level of 6/10 at the incision site: Pain is expected and manageable with interventions, making it less critical.

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A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

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Correct Answer is A

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Correct Answer is A

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