A nurse is preparing to insert a peripheral IV catheter for an older adult client. Which action should the nurse plan to take?
Insert the catheter at a 45-degree angle.
Position the client’s arm in a dependent position.
Remove excess hair from the insertion site.
Initiate IV therapy in the veins of the hand.
The Correct Answer is B
Choice A rationale
Inserting the catheter at a 45-degree angle is not recommended for an older adult client with fragile skin. A lower angle of insertion is usually more appropriate.
Choice B rationale
Positioning the client’s arm in a dependent position can help engorge the veins, making it easier to insert the IV catheter.
Choice C rationale
Removing excess hair from the insertion site is not the first action the nurse should take. While it’s important to have a clean and clear insertion site, positioning the client’s arm correctly is a more immediate concern.
Choice D rationale
Initiating IV therapy in the veins of the hand is not the first action the nurse should take. While the veins of the hand can be used for IV insertion, positioning the client’s arm correctly is a more immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While the top of the cane should be parallel to the client’s greater trochanter, this alone does not indicate correct use of the cane.
Choice B rationale
Advancing the cane 46 cm (18 in) forward while walking is too far. To maintain balance, the client should advance the cane about 15-30 cm (6-12 in) at a time.
Choice C rationale
The client should hold the cane on the stronger side of their body to increase support and maintain alignment. This is an indication of correct use.
Choice D rationale
The client should move their weaker leg forward with the cane. This divides the client’s body weight between the cane and the stronger leg.
Correct Answer is A
Explanation
The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.
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