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 B
Explanation
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.
Correct Answer is D
Explanation
Choice A rationale
While elevating the head of the bed to 30 degrees can be helpful in some procedures, it is not the most crucial step when inserting a nasogastric (NG) tube. The primary goal is to ensure the tube enters the esophagus and not the trachea.
Choice B rationale
If a patient begins to gag or choke during the procedure, it may indicate that the tube has entered the trachea instead of the esophagus. However, removing the NG tube immediately might not always be the best course of action. It’s important to first assess the situation, reposition the patient, and attempt to advance the tube while the patient swallows.
Choice C rationale
Applying suction to the NG tube prior to insertion is not a standard practice. Suction is typically applied after the NG tube has been properly placed and secured, to remove gastric contents for therapeutic (decompression) or diagnostic (analysis) purposes.
Choice D rationale
Encouraging the patient to take sips of water can facilitate the insertion of the NG tube into the esophagus. Swallowing helps guide the tube down into the esophagus instead of the trachea.
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