The charge nurse is observing a new nurse who is preparing to insert an intravenous (IV) catheter.
The new nurse has gathered supplies including intravenous catheters, an intravenous insertion kit, and a 4x sterile gauze dressing to cover and secure the insertion.
What action should the charge nurse take?
Verify that the nurse has gathered the necessary supplies.
Advise the nurse to use a transparent dressing over the site.
Ensure the nurse tapes the gauze dressing securely in place.
Intend to inspect the secured IV site after the insertion procedure.
The Correct Answer is B
Choice A rationale
Verifying that the nurse has gathered the necessary supplies is important, but it is not the most critical action in this scenario. The new nurse has already gathered the necessary supplies for the procedure.
Choice B rationale
This is the correct answer. A transparent dressing is preferred over a gauze dressing for securing an IV catheter. It allows for easy inspection of the insertion site for signs of infection.
Choice C rationale
Ensuring that the gauze dressing is taped securely in place is not the most critical action in this scenario. As mentioned, a transparent dressing is generally preferred for securing an IV catheter.
Choice D rationale
While inspecting the secured IV site after the insertion procedure is important, advising the nurse to use a transparent dressing over the site is a more immediate need. This will allow for continuous visual inspection of the site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Activating the synchronization mode is important during cardioversion to avoid delivering a shock during the vulnerable period of cardiac repolarization, which could potentially cause a life-threatening arrhythmia. However, it is not the most crucial action.
Choice B rationale
Choosing a monitor lead with a tall R wave can help ensure that the cardioverter-defibrillator can sense the patient’s intrinsic cardiac activity. However, this is not the most crucial action.
Choice C rationale
Administering the prescribed sedative is the most crucial action before initiating cardioversion. Sedation is necessary to ensure patient comfort and cooperation during the procedure, as cardioversion can be painful.
Choice D rationale
Verifying the prothrombin time (PT) is important in patients receiving anticoagulation therapy, as atrial fibrillation increases the risk of thrombus formation. However, it is not the most crucial action before initiating cardioversion.
Correct Answer is C
Explanation
Choice A rationale
Monitoring capillary refill distal to the infusion site is a general nursing intervention during IV therapy. However, it is not specific to the administration of a vesicant chemotherapeutic agent.
Choice B rationale
Applying a topical anesthetic at the infusion site for burning is not a standard intervention during the administration of a vesicant chemotherapeutic agent. The burning sensation is not due to the IV site but due to the vesicant agent itself.
Choice C rationale
Assessing the IV site frequently for signs of extravasation is the most appropriate intervention during the administration of a vesicant chemotherapeutic agent. Extravasation, the leakage of the vesicant into the surrounding tissue, can cause severe local tissue damage. Early detection and intervention are crucial to minimize harm.
Choice D rationale
While it is important to explain potential side effects to the client, explaining that temporary burning at the IV site may occur is not the most crucial intervention. The priority is to monitor for and prevent extravasation.
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