Nokea
A nurse is preparing to initiate IV therapy for a client. Which of the following sites should the nurse use to place the peripheral IV catheter?
- A. Nondominant dorsal venous arch
- B. Dominant distal dorsal vein
- C. Nondominant forearm basilic vein
- D. Dominant antecubital vein
Correct Answer: A
Rationale: The correct answer is A: Nondominant dorsal venous arch. This site is preferred for peripheral IV catheter placement due to the larger vein diameter, ease of access, and reduced risk of complications like nerve damage or infiltration. The nondominant side is chosen to prevent disruption of daily activities. The dorsal venous arch is a superficial vein that is easily visible and palpable, making it suitable for successful cannulation. It also allows for optimal flow rate and minimizes the risk of phlebitis. Choices B, C, and D are not ideal for various reasons such as smaller vein size, increased risk of nerve damage, and difficulty in accessing or securing the catheter.
You may also like to solve these questions
A nurse is preparing to administer 4,000 units of heparin subcutaneously to a client who has deep-vein thrombosis. Available is heparin 10,000 units/mL. How many mL of heparin should the nurse administer? (Round to the nearest tenth.)
Correct Answer: 0.4
Rationale: To calculate the mL of heparin to administer, use the formula: desired dose (4,000 units) ÷ concentration (10,000 units/mL) = X mL. 4,000 ÷ 10,000 = 0.4 mL. The correct answer is 0.4 mL because it accurately represents the calculated dose needed for the client. Other choices are incorrect as they do not align with the correct calculation.
Client awake, alert, and oriented to person, place, and time.
Lung sounds clear and equal bilaterally. Heart rhythm regular,
no peripheral edema, capillary refill less than 3 seconds in all
extremities. Abdomen soft and nondistended.
Client has past medical history of acute myocardial infarction 4
weeks ago. Client is taking warfarin 8 mg PO once daily.
Complete the following sentence by using the lists of options. Upon analyzing the assessment findings, the nurse identifies that the client is at risk for Select... due to the Select...
- A. concurrent medication use
- B. recent illness
- C. activity level
Correct Answer: A
Rationale: The correct answer is A: concurrent medication use. The nurse identifies the client is at risk for adverse drug interactions or side effects due to the potential interactions between medications. Recent illness (B) may impact the client's health but does not specifically relate to medication use. Activity level (C) is important but does not directly indicate medication risk. Without options D, E, F, and G, they cannot be considered as potential correct choices.
A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?
- A. Urticaria
- B. Bradycardia
- C. Pallor
- D. Dyspepsia
Correct Answer: A
Rationale: The correct answer is A: Urticaria. Urticaria, or hives, is a classic sign of an allergic reaction. It presents as raised, red, itchy welts on the skin. This occurs due to histamine release in response to the allergen (penicillin in this case). Monitoring for urticaria is crucial as it indicates a potentially serious allergic reaction that may progress to anaphylaxis. Bradycardia (B), Pallor (C), and Dyspepsia (D) are not typically associated with allergic reactions to penicillin. Bradycardia is a slow heart rate, pallor is paleness of the skin, and dyspepsia is indigestion. These symptoms are more likely related to other conditions or side effects rather than an allergic reaction.
A client who has active tuberculosis and is taking rifampin reports that his urine and sweat have developed a red tinge. Which of the following actions should the nurse take?
- A. Check the client's liver function test results.
- B. Instruct the client to increase his fluid intake.
- C. Document this as an expected finding.
- D. Prepare the client for dialysis.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Document this as an expected finding. Rifampin is known to cause harmless discoloration of bodily fluids like urine and sweat. This is a common side effect and does not indicate any serious issues. The nurse should document this finding to track the client's response to the medication and educate the client about it.
Summary of Incorrect Choices:
A: Checking liver function test results is not necessary for the red discoloration caused by rifampin.
B: Increasing fluid intake will not resolve the red tinge as it is a known side effect of rifampin.
D: Dialysis is not indicated for the harmless discoloration caused by rifampin.
A nurse is discussing adverse reactions to pain medications in older adult clients with a newly licensed nurse. Which of the following findings should the nurse include as risk factors for an adverse drug reaction? (SATA)
- A. Polypharmacy
- B. Increased rate of absorption
- C. Decreased percentage of body fat
- D. Multiple health problems
Correct Answer: A,C,D,E
Rationale: To determine risk factors for adverse drug reactions in older adults, consider the following:
A: Polypharmacy increases the likelihood of drug interactions and adverse effects.
C: Decreased body fat can affect drug distribution, leading to higher drug concentrations.
D: Multiple health problems may require multiple medications, increasing the risk of adverse reactions.
E: Age-related changes in liver and kidney function can affect drug metabolism and excretion.
Other choices are incorrect because increased rate of absorption does not necessarily increase risk and choices F and G were not provided.