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 B
Explanation
Choice A reason:
Wearing a mask when outside of the room is not a standard practice for all patients undergoing an allogeneic stem cell transplant. The need for mask use may vary based on the patient's specific condition and the facility's infection control protocols.
Choice B reason:
"You will be in a negative-airflow room to keep the air cleaner." This is the appropriate answer. An allogeneic stem cell transplant involves replacing the patient's damaged or diseased bone marrow with healthy donor stem cells. Patients undergoing this type of transplant have compromised immune systems due to the treatment, which increases the risk of infection. Placing the patient in a negative-airflow room helps prevent the spread of airborne infections by ensuring that air flows into the room but does not escape into other areas of the facility
Choice C reason:
Visitors wearing protective gowns is not a standard practice for all patients undergoing an allogeneic stem cell transplant. Visitor guidelines may depend on the patient's immune status and specific infection control measures.
Choice D reason:
Being placed in a semi-private room is not recommended for patients undergoing an allogeneic stem cell transplant. These patients require a controlled environment to reduce the risk of infections, and private rooms with proper infection control measures are generally preferred.
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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