The nurse is inserting an intravenous line into a client’s vein. After the initial stick, the nurse would continue to advance the catheter in which situation?
The vein is distended under the needle
The client does not complain of discomfort
The catheter advances easily
Blood return shows in the backflash chamber of the catheter
The Correct Answer is D
Choice A reason: Vein distension under the needle may indicate improper placement or infiltration, not successful cannulation. Advancing the catheter without blood return risks extravasation, causing tissue damage or therapy failure.
Choice B reason: Lack of discomfort is not a reliable indicator of proper catheter placement. Patients may not feel pain despite incorrect positioning. Blood return confirms venous access, ensuring safe advancement of the catheter.
Choice C reason: Easy catheter advancement may occur but does not confirm venous placement. Without blood return, the catheter may be in tissue, risking infiltration. Blood return is the definitive sign for safe advancement.
Choice D reason: Blood return in the backflash chamber indicates the catheter is in the vein, confirming successful cannulation. This allows safe advancement, ensuring proper IV therapy delivery without risking extravasation or tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Checking contraindications (e.g., mastectomy, lymphedema, or fistula) prevents complications like infection or swelling. Using an inappropriate extremity risks impaired lymphatic or vascular function, compromising patient safety during IV therapy.
Choice B reason: Starting distally and moving proximally is standard to preserve proximal veins for future use. Starting proximally may limit future access sites, increasing the risk of complications if distal veins are compromised.
Choice C reason: A vein with minimal curvature reduces the risk of catheter kinking or vessel trauma. Straight veins allow smoother catheter advancement, ensuring stable IV access and minimizing infiltration or dislodgement risks.
Choice D reason: Choosing the dominant arm is not standard, as it may limit patient mobility. The non-dominant arm is preferred unless contraindicated, to enhance comfort and reduce disruption during daily activities.
Choice E reason: Avoiding areas of flexion (e.g., elbow) prevents catheter dislodgement or kinking due to movement. Stable sites like the forearm ensure reliable IV access, reducing infiltration and improving therapy effectiveness.
Correct Answer is C
Explanation
Choice A reason: A drop factor of 10 gtts/mL is typical for macrodrip tubing, used for rapid fluid administration in adults. It delivers larger drops, requiring fewer drops per milliliter, unsuitable for microdrop tubing, which is designed for precise, smaller-volume infusions, such as in pediatrics or critical care settings.
Choice B reason: A drop factor of 15 gtts/mL is also associated with macrodrip tubing, used for standard IV infusions in adults. It delivers larger drops than microdrop tubing, making it inappropriate for situations requiring precise control of small fluid volumes, such as in neonatal or critical care scenarios.
Choice C reason: Microdrop tubing has a drop factor of 60 gtts/mL, delivering smaller drops for precise fluid administration. This is critical in pediatrics or when administering small volumes of medication, ensuring accurate dosing and minimizing fluid overload risks in sensitive populations.
Choice D reason: A drop factor of 20 gtts/mL is used in some macrodrip sets, not microdrop tubing. It is designed for general adult infusions, delivering larger drops than microdrop tubing, which is unsuitable for precise, low-volume fluid administration required in specialized settings like pediatrics.
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