A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy?
The radial vein on the left wrist
The cephalic vein on the back of the right hand
The cephalic vein in the left distal forearm
The basilic vein in the right antecubital fossa
The Correct Answer is C
Choice A Reason:
The radial vein on the left wrist is not the best choice because it is on the same side as the right mastectomy, and it is advisable to avoid the same side as the surgical site to minimize potential complications.
Choice B Reason:
The cephalic vein on the back of the right hand is not a suitable choice because it is on the same side as the right mastectomy, and it is generally recommended to avoid the ipsilateral (same-side) arm for IV access in such cases.
When initiating IV therapy for a client following a right mastectomy, it is generally advisable to avoid the arm on the same side as the mastectomy (in this case, the right arm) to minimize the risk of complications. Therefore, the nurse should select a vein in the left arm.
Choice C Reason:
The cephalic vein in the left distal forearm is appropriate. Selecting a vein in the left arm, such as the cephalic vein in the left distal forearm, would help reduce the risk of lymphedema and other complications associated with the right mastectomy site. It is essential to choose an appropriate vein while considering the client's medical history and potential sources of complications.
Choice D Reason:
The basilic vein in the right antecubital fossa is also on the same side as the right mastectomy and should be avoided for the same reasons mentioned above.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
"No changes noted to the wound from previous nursing notes." - This entry is appropriate as it indicates that there are no significant changes in the wound compared to previous assessments, which is important information to document.
Choice B Reason:
"Client premedicated with MSO4 subq prior to dressing change." - This entry is relevant, especially if the client received medication before the procedure, which can impact the client's comfort and pain management.
Choice C Reason:
"New dressing applied as prescribed; no drainage on old dressing." - This entry is appropriate as it provides details about the care given during the dressing change, including the application of a new dressing and the absence of drainage on the old dressing.
Choice D Reason:
"The wound seems clean and does not appear to be infected." - This entry is also appropriate as it describes the nurse's assessment of the wound's condition. It is important to document the nurse's observations and assessment findings.
Correct Answer is D
Explanation
Choice A Reason:
Room number: Room numbers can change, and multiple clients may have the same room number. Using the room number alone does not guarantee the identification of the specific client.
Choice B Reason:
Age: Relying on a client's age alone is not sufficient for accurate identification, as multiple clients of the same age may be present in a healthcare setting. Age is not a unique identifier.
Choice C Reason:
Bed number: Bed numbers, like room numbers, can change, and more than one client may have the same bed number, especially in larger healthcare facilities. Bed numbers alone do not provide a unique client identifier.
When preparing to administer a medication to a client, the nurse should use a reliable client identifier to ensure that the right medication is given to the right patient. The correct client identifier is:
Choice D Reason:
Photograph is correct. Using a photograph is a reliable way to confirm the client's identity, especially in settings where photograph identification is routinely used, such as inpatient hospital units. It helps eliminate the risk of medication errors and ensures that the nurse is administering the medication to the correct client.
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