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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
While having a case management evaluation of the client’s home environment can provide valuable information and potential solutions for caregiving challenges, it does not directly address the caregiver’s immediate need for relief and support.

Choice B rationale

Hiring a private duty nurse could provide the caregiver with some time away from caregiving duties. However, this may not be a feasible option for many caregivers due to the cost associated with private nursing care.

Choice C rationale
Proposing that extended family could return to the area to help provide assistance assumes that such help is available and willing. This may not be the case for many caregivers.

Choice D rationale
Suggesting that social services be contacted to find a respite care facility for the client directly addresses the caregiver’s need for relief and support. Respite care provides temporary relief for primary caregivers, allowing them to rest and take care of their own needs. This can help to alleviate symptoms of caregiver burnout, such as poor sleep and frequent crying.

A. Monitor capillary refill distal to the infusion site. B. Apply a topical anesthetic at the infusion site for burning. C. Assess IV site frequently for signs of extravasation. D. Explain that temporary burning at the IV site may occur.

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?

Correct Answer is C

Explanation

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