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 C
Explanation
Choice A reason:
Protective precautions are not necessary because they (also known as reverse isolation) are used for immunocompromised clients to protect them from potential pathogens carried by healthcare workers or visitors.
Choice B reason:
Droplet precautions are not necessary because they are used for infections spread through larger respiratory droplets, like influenza or pertussis.
Choice C reason:
Airborne precautions should be implemented by the nurse. Tuberculosis (TB) is primarily transmitted through the airborne route, as the bacteria that cause TB can be suspended in the air as tiny particles (droplet nuclei) when an infected person coughs, sneezes, speaks, or sings. These particles can be inhaled by others, leading to the potential transmission of the disease.
Choice D reason:
Contact precautions are not necessary because they are used for infections that are transmitted through direct contact with the client or contaminated surfaces, such as MRSA (Methicillin-resistant Staphylococcus aureus) or C. difficile.
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.
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