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.
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A nurse is caring for a client in a provider's office. Which of the following statements should the nurse include when teaching the client about the prescribed medication? Select all that apply.
- A. The medication can cause nausea, so take with a meal
- B. You can experience vivid nightmares."
- C. You may notice your urine becomes lighter in color
- D. Consumption of a high protein meal can reduce the effectiveness of the medication
- E. You may initially notice an increase in involuntary movements
- F. This medication can make you light-headed if you stand up too quickly from a seated or lying position
Correct Answer: A, B, E, F
Rationale: Correct Answer: A, B, E, F
Rationale:
A: Taking the medication with a meal can help reduce nausea, enhancing tolerance.
B: Mentioning vivid nightmares prepares the client for a potential side effect.
E: Increase in involuntary movements is a common side effect of certain medications.
F: Informing about potential dizziness upon standing up quickly promotes safety.
These statements address medication effects and side effects, promoting client understanding and safety.
Incorrect Choices:
C: Urine color change may not be relevant to the medication being discussed.
D: High protein meal interaction is not mentioned for this medication.
Incorrect choices lack relevance or do not address potential medication effects, making them not suitable for client education.
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 assessing a client's IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?
- A. Slow the IV solution rate
- B. Initiate a new IV distal to the initial site
- C. Maintain the extremity below the level of the heart
- D. Apply a warm, moist compress
Correct Answer: D
Rationale: The correct action is to apply a warm, moist compress (Choice D). This helps improve circulation and reduce edema by promoting vasodilation and enhancing tissue perfusion. Cooling and edematous IV sites indicate impaired circulation, which can lead to complications like phlebitis. Slowing the IV rate (Choice A) may not address the underlying issue. Initiating a new IV distal to the initial site (Choice B) may not improve circulation in the affected area. Maintaining the extremity below heart level (Choice C) can worsen edema.
A nurse is caring for a client who is taking digoxin to treat heart failure. Which of the following predisposes this client to developing digoxin toxicity?
- A. Taking a high ceiling diuretic
- B. Having a 10-year history of COPD
- C. Having a prolapsed mitral valve
- D. Taking an HMG CoA reductase inhibitor
Correct Answer: A
Rationale: The correct answer is A: Taking a high ceiling diuretic. High ceiling diuretics, such as furosemide, can lead to hypokalemia, which increases the risk of digoxin toxicity. Digoxin competes with potassium for binding sites on the Na+/K+-ATPase pump in the heart, so low potassium levels can lead to an increased concentration of digoxin in the body, predisposing the client to toxicity. Choices B, C, and D are incorrect as they do not directly impact digoxin levels or toxicity. A history of COPD (B) or a prolapsed mitral valve (C) do not specifically predispose a client to digoxin toxicity. Taking an HMG CoA reductase inhibitor (D) does not interact directly with digoxin.
A nurse is preparing to administer potassium chloride elixir 20 mEq/day PO to divide equally every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round to the nearest tenth.)
Correct Answer: 7.5
Rationale: The correct answer is 7.5 mL. To determine this, first calculate the total daily dose: 20 mEq/day ÷ 2 doses/day = 10 mEq/dose. Next, find the mL per dose using the available concentration: 10 mEq ÷ 6.7 mEq/5 mL = 7.46 mL, which rounds to 7.5 mL. This ensures the patient receives the correct dose of potassium chloride elixir. Other choices are incorrect because they do not follow the correct calculation or rounding process, leading to potential under or overdosing.