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 ["100"]
Explanation
Step 1: The child is receiving gentamicin 60 mg every 8 hours IV, which is to be infused over 30 minutes. The medication is delivered by the pharmacy diluted in a 50 ml bag of saline.
Step 2: We need to find the infusion pump’s regulation in mL/hour.
Step 3: Since the medication is to be infused over 30 minutes, we convert this to hours by dividing by 60. So, 30 minutes is 0.5 hours.
Step 4: The rate of infusion is then the total volume (50 mL) divided by the time in hours (0.5 hours).
Step 5: So, the infusion pump’s regulation is (50 mL ÷ 0.5 hours) = 100 mL/hour.
Correct Answer is B
Explanation
Choice A rationale
A blood glucose level of 90 mg/dL (5 mmol/L) is within the normal range and would not need to be reported to the surgeon.
Choice B rationale
A serum creatinine level of 5 mg/dL (442 µmol/L) is significantly elevated, indicating impaired kidney function. This is a critical lab value that should be reported to the surgeon immediately, as it could impact the patient’s ability to safely undergo surgery and recover postoperatively.
Choice C rationale
A hemoglobin level of 13 g/dL (130 g/L) is within the normal range and would not need to be reported to the surgeon.
Choice D rationale
A potassium level of 4 mEq/L (4 mmol/L) is within the normal range and would not need to be reported to the surgeon.
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