The nurse is preparing to perform a venipuncture on a patient. Which of the following is an appropriate action for the nurse to take?
a. Apply the tourniquet until the distal pulse is no longer felt.
b. Remove the tourniquet after 1 minute.
c. Instruct the patient to vigorously open and close the fist.
d. Do not use veins that rebound.
B
Do not keep a tourniquet on the patient longer than 1 minute. Prolonged tourniquet application causes stasis, localized acidemia, and hemoconcentration. Palpate the distal pulse (e.g., brachial) below the tourniquet. If the pulse is not palpable, reapply the tourniquet more loosely. Ask the patient to open and close the fist several times, finally leaving the fist clenched. Instruct the patient to avoid vigorous opening and closing of the fist. Palpate for a firm vein that rebounds; a patent, healthy vein is elastic and rebounds on palpation.
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