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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

This statement is incorrect. Advance directives do not allow the court to overrule an adult client’s refusal of medical treatment. They are legal documents that provide instructions for medical care and only go into effect if the individual cannot communicate their own wishes.

Choice B rationale

This statement is correct. Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. They allow individuals to express their preferences about medical treatment at some point in the future, should they become unable to communicate their wishes.

Choice C rationale

This statement is incorrect. Advance directives do not permit a client to withhold medical information from health care personnel. They are used to communicate the individual’s wishes about medical treatment to their healthcare providers and family.

Choice D rationale

This statement is incorrect. Advance directives do not specifically allow health care personnel in the emergency department to stabilize a client’s condition. They are used to guide choices for doctors and caregivers if the individual is terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

A. Insert the suction catheter while the patient is swallowing. B. Apply intermittent suction when withdrawing the catheter. C. Place the catheter in a location that is clean and dry for later use. D. Hold the suction catheter with their clean, non-dominant hand.

Correct Answer is B

Explanation

Choice A rationale

Inserting the suction catheter while the patient is swallowing is not the recommended technique for nasotracheal suctioning. This could cause discomfort and potentially lead to aspiration.

Choice B rationale

Applying intermittent suction when withdrawing the catheter is the correct technique for nasotracheal suctioning. This helps to remove secretions effectively while minimizing trauma to the nasal and tracheal mucosa.

Choice C rationale

Placing the catheter in a location that is clean and dry for later use is not a recommended practice. After suctioning, the catheter should be properly cleaned or disposed of to prevent infection.

Choice D rationale

Holding the suction catheter with their clean, non-dominant hand is not a recommended practice. The nurse should use clean gloves and proper hand hygiene when performing nasotracheal suctioning to prevent infection.

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A nurse is preparing to insert a peripheral IV catheter for an older adult client. Which action should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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