A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?
Select a site on the client’s dominant arm.
Apply a tourniquet below the venipuncture site.
Elevate the client’s arm prior to insertion.
Choose a vein that is palpable and straight.
The Correct Answer is D
This will facilitate the insertion of the catheter and reduce the risk of complications such as infiltration, phlebitis, or hematoma. A straight vein will also allow the catheter to be inserted up to the hub, which reduces the risk of contamination along the length of the catheter.
Choice A is wrong because selecting a site on the client’s dominant arm can interfere with the client’s mobility and increase the risk of dislodging the catheter. The nurse should choose a site on the client’s non-dominant arm, preferably on the hand or forearm.
Choice B is wrong because applying a tourniquet below the venipuncture site will impede blood flow and make it harder to locate a suitable vein. The nurse should apply a tourniquet above the venipuncture site, about 10 to 15 cm from the insertion site.
Choice C is wrong because elevating the client’s arm prior to insertion will decrease venous filling and make it harder to palpate a vein. The nurse should lower the client’s arm below the level of the heart to increase venous distension.
Normal ranges for IV catheter size and insertion angle depend on several factors, such as the type and duration of therapy, the condition and size of the vein, and the age and preference of the client.
In general, smaller gauge catheters (20 to 24) are preferred for peripheral IV therapy, and larger gauge catheters (14 to 18) are used for rapid fluid administration or blood transfusion. The insertion angle can vary from 10 to 30 degrees, depending on the depth and location of the vein.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choicea. Swelling of the face.
Choice A rationale:
Swelling of the face can be a sign of preeclampsia, a serious condition that requires immediate medical attention.Preeclampsia can lead to complications for both the mother and the baby if not managed properly.
Choice B rationale:
Urinary frequency is a common symptom during pregnancy due to hormonal changes and the growing uterus pressing on the bladder.It is generally not a cause for concern unless accompanied by other symptoms like pain or burning during urination.
Choice C rationale:
Faintness upon rising, also known as orthostatic hypotension, is common in pregnancy due to changes in blood circulation.It can often be managed by rising slowly and ensuring adequate hydration.
Choice D rationale:
Bleeding gums are common during pregnancy due to hormonal changes that increase blood flow to the gums, making them more sensitive and prone to bleeding.Good oral hygiene can help manage this symptom.
Correct Answer is D
Explanation
The correct answer is choice D: A client who is taking warfarin and has an INR of 1.8.
Choice A rationale:
A Mantoux test with an induration after 48 hours can be a normal reaction, especially if the induration is within the expected size range for a positive result, depending on the individual’s risk factors and history. It does not necessarily require follow-up care unless the induration is significantly large or there are other concerning symptoms.
Choice B rationale:
A client scheduled for a colonoscopy and taking sodium phosphate does not typically require follow-up care for the sodium phosphate intake itself. Sodium phosphate is commonly used as a bowel prep medication to clear the intestines prior to the procedure.
Choice C rationale:
A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L), so a client taking bumetanide with this potassium level would not typically require follow-up care for the potassium level alone.
Choice D rationale:
A client taking warfarin with an INR of 1.8 requires follow-up care because the therapeutic range for warfarin is typically between 2.0 and 3.0 for most indications. An INR of 1.8 may indicate that the blood is not “thin” enough, increasing the risk of thrombotic events, and the warfarin dose may need adjustment.
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