A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take?

Select a vein on the back of the hand.

Clean the site using vigorous friction.

Use a 22-gauge catheter for insertion.

Apply a tourniquet firmly above the insertion site.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Select a vein on the back of the hand: Veins on the dorsum of the hand are often more fragile and prone to infiltration or rupture in older adults. Using a more proximal site, such as the forearm, is generally safer and more stable for IV therapy.

B. Clean the site using vigorous friction: Older adults often have thinner, more delicate skin that can tear easily. While proper antiseptic technique is important, vigorous friction can cause skin trauma and should be avoided during site preparation.

C. Use a 22-gauge catheter for insertion: A 22-gauge catheter is appropriate for older adults because it minimizes vein trauma while still allowing for adequate flow rates. This size is effective for most fluids and medications while reducing the risk of vessel damage.

D. Apply a tourniquet firmly above the insertion site: Applying a tourniquet too tightly can injure fragile veins or cause them to collapse. In older adults, using minimal pressure or alternative vein-dilation methods like warm compresses is often safer.

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Correct Answer is A

Explanation

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

A. Increased platelet count B. Increased protein in urine C. Decreased BUN D. Decreased serum uric acid

Correct Answer is B

Explanation

Rationale:

A. Increased platelet count: Preeclampsia is often associated with thrombocytopenia (low platelet count), not an increase. A falling platelet count can be a warning sign of worsening disease or progression to HELLP syndrome.

B. Increased protein in urine: Proteinuria is one of the hallmark signs of preeclampsia, resulting from glomerular damage in the kidneys. A 24-hour urine protein test or dipstick is commonly used to detect elevated protein levels during pregnancy.

C. Decreased BUN: Blood urea nitrogen (BUN) may increase if renal perfusion is compromised, but a decrease is not typical in preeclampsia. Kidney involvement often leads to elevated BUN and creatinine levels.

D. Decreased serum uric acid: Preeclampsia usually causes elevated serum uric acid levels due to decreased renal clearance. A drop in uric acid would be inconsistent with this diagnosis

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A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take?

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