A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?
Place the tourniquet above the proposed insertion site.
Place the extremity in a dependent position.
Choose the most proximal site on the extremity selected.
Apply a cool compress for several minutes before insertion of the IV catheter.
The Correct Answer is A
Choice A reason:
When preparing to insert an IV catheter, placing the tourniquet above the 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B, C, E, D, A
Explanation
B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.
C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.
E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.
D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort.
Correct Answer is A
Explanation
Choice A reason:
The client has expressed a lack of understanding about the procedure, which indicates that they may not have received sufficient information or clarification. It is important to notify the provider so they can ensure the client fully understands the procedure before giving informed consent.
Choice B reason:
The nurse should provide basic information and answer questions within their scope, but detailed explanations about the procedure are best provided by the provider who is performing the surgery.
Choice C reason:
While brochures can be helpful, they do not replace the need for direct, clear communication with the healthcare provider about the specific details of the surgery.
Choice D reason:
An incident report is not necessary in this context as the situation is related to informed consent and not an error or safety issue.
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