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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Changed mental status: Older adults often exhibit atypical signs of infection, such as confusion, agitation, or other changes in mental status, rather than classic symptoms like fever or dysuria.
B. Temperature 37.3° C (99.1° F): This temperature is within normal range and does not indicate an infection. Older adults may not always mount a fever with infections.
C. WBC count 9,000/mm³ (5,000 to 10,000/mm³): This is within the normal range, so it does not suggest infection. An elevated WBC count (>10,000/mm³) may indicate an infection.
D. Diminished reflexes: This is not a symptom of a bladder infection. It is more commonly associated with neurological or musculoskeletal conditions.
Correct Answer is A
Explanation
A. "I can decrease my risk for a stroke by losing excess weight.": Excess weight is a modifiable risk factor for stroke, and losing weight can improve glycemic control, blood pressure, and cholesterol levels, reducing stroke risk.
B. "My risk for a stroke increases if my HbA1c level is 5 percent or less.": An HbA1c level of 5% is excellent and indicates good glycemic control, which reduces stroke risk.
C. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke.": A cholesterol level below 200 mg/dL is desirable and lowers the risk of cardiovascular events, including stroke.
D. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.": Glucocorticoids are not used to reduce stroke risk; they can actually increase blood sugar and cardiovascular risk if used long-term.
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