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 in the left distal forearm

The cephalic vein on the back of the right hand

The basilic vein in the right antecubital fossa

Answer and Explanation

The Correct Answer is B

When selecting a vein for IV therapy, it is important to consider several factors, including accessibility, integrity, and suitability of the vein. In this case, the client has undergone a right mastectomy, which means the right arm and hand on the affected side might be compromised due to surgery and potential lymphedema. Therefore, it is advisable to avoid using the veins on the affected side.

The cephalic vein in the left distal forearm is a suitable choice because it is on the opposite side of the mastectomy and provides accessibility for venipuncture. It is important to assess the integrity and condition of the vein before insertion to ensure it can accommodate the IV catheter and maintain patency throughout the infusion.

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Correct Answer is C

Explanation

A. Change the tubing set every 72 hr:
Enteral feeding sets should generally be changed every 24 hours to reduce the risk of bacterial contamination.

B. Heat the formula to 40.5° C (105° F):
Enteral formula should be administered at room temperature. Heating it can alter the composition and pose a burn risk to the gastrointestinal mucosa.

C. Aspirate residual volume every 4 hr:
This is recommended to assess tolerance to the feeding and prevent complications like aspiration. Holding feedings may be considered based on facility policy if residuals are high.

D. Flush the tubing with 10 mL of water every 2 hr:
While flushing is necessary to maintain patency, the typical flush is 30 mL every 4 hr (or before and after medications/feedings), unless otherwise specified.

A. Have the client nod to indicate understanding B. Address all questions to the interpreter. C. Use medical terminology when explaining the procedure. D. Recommend an interpreter who is the same gender as the client

Correct Answer is B

Explanation

It is essential to involve a qualified interpreter who can accurately convey information and ensure that the client fully understands the details of the procedure, potential risks, and benefits. The interpreter serves as a bridge between the nurse and the client, allowing for clear and accurate communication.

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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?

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