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
The correct answer is choice D. The nurse should choose a vein that is palpable and straight for IV catheter insertion.
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 C
Explanation
The correct answer is C. Refrigerate the medication after reconstitution.
Penicillin G is a short-acting penicillin that is usually administered by intravenous infusion or intermittent piggyback injections. The powder for injection should be dissolved in water for injection or 0.9% sodium chloride and stored in a refrigerator at 2° to 8°C (36° to 46°F) for up to 7 days.
If the medication is not refrigerated, it may lose its potency and effectiveness.
Choice A is wrong because infusing the medication over 10 min is too fast and may cause adverse effects such as convulsions. The recommended infusion time for penicillin G is 30 to 60 minutes.
Choice B is wrong because instructing the client to notify the provider if diarrhea develops is not specific to penicillin
G. Diarrhea is a common side effect of many antibiotics and does not indicate an allergy or toxicity. However, the client should be advised to report signs of severe or bloody diarrhea, which may indicate pseudomembranous colitis.
Choice D is wrong because checking the client for a sulfa allergy is not relevant to penicillin
G. Sulfa drugs are a different class of antibiotics that may cause allergic reactions in some people, but they are not cross-reactive with penicillins. However, the nurse should check the client for a penicillin allergy or a cephalosporin allergy, as these drugs may have crosssensitivity.
Correct Answer is C
Explanation
Choice A option:
Complete oral hygiene is not appropriate. While maintaining good oral hygiene is important, it is not directly related to preparing for postural drainage.
Choice B option
Use an albuterol inhaler is not appropriate option. Albuterol is a bronchodilator that helps open the airways, but its use is more commonly associated with managing acute episodes of bronchospasm and not specifically related to postural drainage preparation.
Choice C option:
Take pancrelipase is the correct option, Prior to initiating postural drainage, the nurse should instruct the adolescent client with cystic fibrosis to take pancrelipase. Pancrelipase is a pancreatic enzyme replacement medication that helps individuals with cystic fibrosis digest and absorb nutrients from their food properly.
Cystic fibrosis is a genetic disorder that affects various organs, including the lungs and the pancreas. It leads to the production of thick, sticky mucus, which can obstruct the airways and the pancreatic ducts, causing respiratory and digestive issues.
Choice D option:
Eat a meal is not appropriate answer. It is generally recommended to avoid heavy meals or overeating before postural drainage to reduce the risk of aspiration during the procedure. However, taking pancrelipase is a more specific action related to managing cystic fibrosis and its digestive complications.
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