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 cephalic vein on the back of the right hand
The radial vein on the left wrist
The basilic vein in the right antecubital fossa
The cephalic vein in the left distal forearm
The Correct Answer is C
Choice A reason:
The cephalic vein on the back of the right hand is incorrect because it might still involve the same arm as the mastectomy site, and it is important to avoid this side.
Choice B reason:
The radial vein on the left wrist is incorrect because it is not on the opposite side of the mastectomy and could increase the risk of lymphedema.
Choice C reason:
The basilic vein in the right antecubital fossa is the appropriate answer. When inserting an IV catheter for a client who has undergone a right mastectomy, it is generally advisable to avoid the arm on the same side as the mastectomy due to the risk of lymphedema and impaired lymphatic drainage. The basilic vein in the right antecubital fossa (the inner bend of the right elbow) would be a suitable choice in this case, as it is on the opposite side of the mastectomy.
Choice D reason:
The cephalic vein in the left distal forearm is on the same side as the mastectomy and should be avoided to reduce the risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Placing the wasted portion of the controlled substance in the sharp container is not correct. Wasted controlled substances should be disposed of according to specific regulations and facility protocols.
Choice B reason:
Asking a second nurse to record her signature when wasting an unused portion of the controlled substance is not a standard practice. The process for wasting controlled substances usually involves following specific documentation procedures, but this does not necessarily require a second nurse's signature.
Choice C reason:
Over-verifying the count total of the controlled substance after removing the amount needed is not a standard practice. It's important to maintain accurate records and documentation, but additional verification of the count total may not be necessary in this context.
Choice D reason:
Reporting any discrepancy in the count total of the controlled substance after administration is the appropriate action. When administering a controlled substance, it is important to accurately account for the medication before and after administration. Any discrepancy in the count of the controlled substance should be reported and documented according to facility policy. This helps ensure proper tracking and accountability of controlled substances, which is crucial for maintaining patient safety and preventing potential diversion or misuse.
Correct Answer is A
Explanation
Choice A reason:
When preparing to insert an IV catheter, placing the tourniquet abovethe proposed insertion site helps facilitate venous distension and makes it easier to locate a suitable vein for the catheter insertion. This technique helps to improve visibility and access to the vein.
Choice B reason:
Placing the extremity in a dependent position (lower than the heart) can increase venous pressure and make it more difficult to insert the catheter.
Choice C reason:
Choosing the most proximal site on the extremity is not always necessary or appropriate. Veins distal to the proposed insertion site should be considered first, as they tend to be smaller and less accessible.
Choice D reason:
Applying a cool compress is not typically done before IV catheter insertion. It might cause vasoconstriction and make it more difficult to access a suitable vein.
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