Nokea
When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:
- A. Choose a proximal site.
- B. Choose a distal site.
- C. Have the patient hold his arm over his head.
- D. Leave the tourniquet on for at least 5 minutes.
Correct Answer: B
Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Selection of a distal site leaves the upper veins available for subsequent cannulations. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes.
You may also like to solve these questions
The renin and angiotensin systems help to maintain the balance of sodium and water in the body. What other functions do these systems serve?
- A. Regulating hemoglobin levels
- B. Maintaining a healthy blood volume
- C. Releasing platelets when tissues are injured
- D. Lowering blood volumes
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 65-year-old male patient was admitted to a medical-surgical unit 72 hours ago with pyloric stenosis; a nasogastric tube was inserted upon admission and has been on low intermittent suction since then. The nurse taking care of the patient notices that his potassium is very low and becomes concerned that the patient may be at risk for:
- A. Hypercalcemia
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: C
Rationale: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia.
A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that ¢â‚¬Å“she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.¢â‚¬ The nurse explains to the woman that:
- A. She will need to have her medications adjusted and be readmitted to the hospital for a complete workup.
- B. Limiting fluids can create imbalances in the body that can result in confusion; maybe we need to adjust the timing of your fluids.
- C. It is normal to be a little confused following surgery and it safe not to urinate at night.
- D. Confusion following surgery is common in the elderly due to loss of sleep.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse preparing to start an IV on a newly admitted patient teaches the patient about the procedure and begins to prepare the site. The nurse should always start by:
- A. Leaving one hand ungloved to assess the site
- B. Preparing the skin with an iodine solution
- C. Asking the patient if he is allergic to latex or iodine
- D. Removing excessive hair at the selected site
Correct Answer: C
Rationale: Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in setting up for IV therapy. A local reaction could result in irritation to the IV site or, in the extreme, it could result in anaphylaxis, which can be life threatening.
The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Increased PaCO2
- D. Central nervous system (CNS) disturbances
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.