The nurse is preparing to insert a peripheral intravenous (IV) line. Which technique should the nurse implement to prepare for the IV insertion?
a. Slap the selected vein gently several times.
b. Select a proximal site on the extremity.
c. Shave the hair in the area of the insertion site.
d. Tie a tourniquet above the selected inser-tion site.
D
The nurse applies a tourniquet to the patient's arm to engorge the vein selected for IV insertion. This facilitates catheter insertion because a larger vein is easier to enter without transecting the vein than a small vessel. The nurse avoids tapping and massaging the vein before IV insertion because these actions increase the risks of hematoma formation and vasoconstriction. The most distal site on the extremity suitable for IV therapy is selected, and hair around the potential IV insertion site is clipped not shaved, because shaving increases the risks of impaired skin integrity and infection through microabrasions.
You might also like to view...
A clinic nurse is following a 9-year-old boy who is taking somatropin. Which of the following will the nurse monitor periodically?
A) Antidiuretic hormone (ADH) levels B) Height C) Dehydration D) Water retention
While undergoing a kidney transplant from a nonfamily member, the patient's transplanted kidney has just had the arterial clamps removed. The OR staff notice that the organ is turning purple with no urine output
When explaining to the family why they had to remove the donor kidney, the nurse will anticipate that the surgeon would likely include which statement? A) Obviously, there has been a mismatch during the human leukocyte antigen (HLA) testing. B) The circulating B and T lymphocytes are just doing their job. C) Hyperacute rejection occurs because antibodies against HLA antigens are deposited in vessels causing necrosis. D) Previous exposure to the HLA antigens is responsible for the high titers of complement fixing antibodies that cause the rejection.
A patient with a colostomy continues to worry about odor. What instruction should a nurse provide to allay this concern?
a. Pierce the top of the appliance bag with a pin to allow gas to escape. b. Rinse the pouch in a vinegar solution. c. Wear tight-fitting underwear. d. Improve personal hygiene.
The client at risk for dehydration is on strict intake and output. In addition, the client has a large draining wound. What action should the nurse take regarding fluid lost through wound drainage?
A. No action needs to be taken because wound drainage is considered insensible loss and is of no consequence. B. Estimate the amount of wound drainage by the color of the stains on the dressing. C. Weigh the dressing materials before and after the dressing change. D. Weigh the client before and after the dressing change.