The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:
flush the catheter with normal saline prior to and after medications.
secure the IV catheter to the extremity.
assess IV site frequently throughout the shift.
prevent contamination during the catheter insertion.
The Correct Answer is C
C. Regular assessment of the IV site is crucial to detect early signs of infiltration. Signs of infiltration include swelling, coolness, pain, or blanching around the insertion site. Assessing the site allows nurses to intervene promptly if infiltration occurs, preventing further complications such as tissue damage or fluid overload.
A. Flushing the IV catheter with normal saline helps to maintain patency and prevent blockage of the catheter. It also ensures that medications are effectively delivered into the bloodstream. While this action is important for maintaining the function of the IV catheter, it primarily addresses patency rather than preventing infiltration directly.
B. Securing the IV catheter to the extremity with a securement device (such as tape or a transparent dressing) helps prevent accidental dislodgement or movement of the catheter. This reduces the risk of
mechanical irritation at the insertion site, which can contribute to infiltration. Proper securement also ensures that the catheter remains in place during movement or patient activities.
D. Proper technique during catheter insertion helps reduce the risk of infection and subsequent complications, but it also indirectly contributes to preventing infiltration. Contamination during insertion can lead to inflammation or infection at the site, which may increase the risk of infiltration due to compromised tissue integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Before administering a cleansing enema, the client is typically instructed to assume a left-side lying position with the right knee bent. This position helps to facilitate the flow of the enema solution into the colon and allows for better retention of the solution. It also helps to prevent leakage and discomfort during the procedure.
A. Drinking water before administering an enema can help hydrate the client and promote normal bowel function. However, it is not typically a specific instruction related to the administration of the enema itself. Hydration is generally beneficial for bowel health but is not directly related to the enema procedure.
B. After administering the enema solution, the client should be instructed to hold the solution in the bowel for a sufficient amount of time to allow it to soften and loosen stool. The exact duration can vary based on the type and purpose of the enema, but typically, the client is encouraged to retain the solution for a specified period (as instructed by the healthcare provider) before evacuating.
C. This instruction is unrelated to the administration of a cleansing enema. Breathing techniques may be taught for relaxation or to manage discomfort during procedures, but they do not specifically apply to the process of administering an enema.
Correct Answer is A
Explanation
A. By actively listening, the nurse shows empathy and a willingness to understand the client's perspective. Understanding significant events like a cancer diagnosis can help the nurse better anticipate the client's emotional and psychological needs.
B. This action shows support and encouragement for the client's achievements in managing their condition. It demonstrates the nurse's awareness of the client's efforts and competence in self-care. While it is positive reinforcement and supportive, it focuses more on the client's physical abilities rather than a deeper understanding of their personal experiences or emotions.
C. This action shows attentiveness to the client's physical comfort and emotional well-being. Offering a back rub during a bed bath can be soothing and comforting, addressing both physical and emotional needs. It demonstrates a caring approach to providing care that considers the client's comfort and relaxation.
D. Eye contact is an important non-verbal communication skill that conveys attentiveness and respect. It helps establish a connection and rapport between the nurse and the client. While maintaining eye contact is important for effective communication and building trust, it alone does not necessarily illustrate knowing the client in terms of understanding their personal experiences or emotions.
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