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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.)

A.

Apply pressure to the venipuncture site with sterile gauze.

B.

Perform hand hygiene.

C.

Clamp the IV tubing.

D.

Withdraw the catheter from the client's vein.

E.

Remove the dressing and tape from the venipuncture site.

Answer and Explanation

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

Correct order:

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

Rationale:

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


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Correct answer: The nurse should first plan to determine if the nasogastric tube is in the correct position, followed by monitoring the client's electrolyte levels.

Determine if the nasogastric tube is in the correct position: It is crucial to ensure the nasogastric tube is correctly positioned to allow for proper drainage and to prevent complications such as aspiration.

Monitor the client's electrolyte levels: Given the client’s abnormal laboratory results (low sodium and potassium levels), it's important to closely monitor electrolytes to prevent further imbalances and complications.

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.

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