A nurse is preparing to initiate IV therapy for an older adult client. Which actions should
the nurse plan to take?
A) Use a disposable razor to remove excess hair on the extremity.
B) Select the back of the client's hand to insert the IV catheter.
C) Distend the veins by using a blood pressure cuff.
D) Direct client to raise his arm above the heart.
Give this one a try later!
Answer: C
Rationale:
- Nurse should distend the veins using a blood pressure cuff to reduce
overfilling of the vein, which can result in a hematoma.
- With an older adult, nurse should select a site on the arm because older
adult typically have fragile veins in the back of their hands.
- Nurse should tell pt. to hold arm below the level of their heart to distend the
vein.
, - Nurse should remove excess hair by clipping it with scissors. Shaving with
disposable razor can cause skin damage that can lead to infection.
A nurse assessing a client's IV catheter insertion site notes a hematoma. Which of the
following actions should the nurse take? (Select all that apply.)
A) Stop the infusion.
B) Apply alcohol to the insertion site.
C) Apply warm compresses to the insertion site
D) Elevate the client's arm.
E) Obtain a specimen for culture at the insertion site
Give this one a try later!
Answer: C, D
Rationale:
- Warm compresses help promote healing and elevation of pts. arm helps
reduce edema.
- Hematoma formation is generally the result of an injury to blood vessels on
insertion of an IV catheter. It does not affect patency of the line or cause
further injury unless hematoma is expanding, so it is not necessary to stop
infusion. However it is necessary to stop the bleeding if it is expanding.
- Alcohol will cause discomfort and increase capillary bleeding. Specimen for
culture is not needed since hematoma is not a result of infection.
Nurse preparing to give furosemide 80mg PO daily. Amount available is oral solution
10mg/1mL. How many mL should nurse give? ( round to whole number).
Give this one a try later!
, 80/10 = 8mL
A nurse orienting a newly licensed nurse is reviewing the procedure for taking a
telephone prescription. Which of the following statements should the nurse identify as an
indication that the newly licensed nurse understands the process?
A) "A second nurse enters the prescription into the client's medical record."
B) "Another nurse should listen to the phone call."
C) "The provider can clarify the prescription when he signs the health record."
D) "I should omit the 'read back' if this is a one‑time prescription
Give this one a try later!
Answer: B
Rationale:
- second nurse should listen to telephone prescription to prevent errors in
communication.
- nurse who accepts the telephone prescription should enter it into the clients
medical record to prevent errors in translation. Nurse should verify that
prescription is correct and accurate at the time she takes it by reading it back
to the prescribing provider. Telephone prescriptions including reading back all
types of medication prescriptions.
Nurse is preparing to give D5W 750 mL IV infuse over 6 hr. Nurse should set IV pump to
deliver how many mL/hr? (Round to whole number).
Give this one a try later!
the nurse plan to take?
A) Use a disposable razor to remove excess hair on the extremity.
B) Select the back of the client's hand to insert the IV catheter.
C) Distend the veins by using a blood pressure cuff.
D) Direct client to raise his arm above the heart.
Give this one a try later!
Answer: C
Rationale:
- Nurse should distend the veins using a blood pressure cuff to reduce
overfilling of the vein, which can result in a hematoma.
- With an older adult, nurse should select a site on the arm because older
adult typically have fragile veins in the back of their hands.
- Nurse should tell pt. to hold arm below the level of their heart to distend the
vein.
, - Nurse should remove excess hair by clipping it with scissors. Shaving with
disposable razor can cause skin damage that can lead to infection.
A nurse assessing a client's IV catheter insertion site notes a hematoma. Which of the
following actions should the nurse take? (Select all that apply.)
A) Stop the infusion.
B) Apply alcohol to the insertion site.
C) Apply warm compresses to the insertion site
D) Elevate the client's arm.
E) Obtain a specimen for culture at the insertion site
Give this one a try later!
Answer: C, D
Rationale:
- Warm compresses help promote healing and elevation of pts. arm helps
reduce edema.
- Hematoma formation is generally the result of an injury to blood vessels on
insertion of an IV catheter. It does not affect patency of the line or cause
further injury unless hematoma is expanding, so it is not necessary to stop
infusion. However it is necessary to stop the bleeding if it is expanding.
- Alcohol will cause discomfort and increase capillary bleeding. Specimen for
culture is not needed since hematoma is not a result of infection.
Nurse preparing to give furosemide 80mg PO daily. Amount available is oral solution
10mg/1mL. How many mL should nurse give? ( round to whole number).
Give this one a try later!
, 80/10 = 8mL
A nurse orienting a newly licensed nurse is reviewing the procedure for taking a
telephone prescription. Which of the following statements should the nurse identify as an
indication that the newly licensed nurse understands the process?
A) "A second nurse enters the prescription into the client's medical record."
B) "Another nurse should listen to the phone call."
C) "The provider can clarify the prescription when he signs the health record."
D) "I should omit the 'read back' if this is a one‑time prescription
Give this one a try later!
Answer: B
Rationale:
- second nurse should listen to telephone prescription to prevent errors in
communication.
- nurse who accepts the telephone prescription should enter it into the clients
medical record to prevent errors in translation. Nurse should verify that
prescription is correct and accurate at the time she takes it by reading it back
to the prescribing provider. Telephone prescriptions including reading back all
types of medication prescriptions.
Nurse is preparing to give D5W 750 mL IV infuse over 6 hr. Nurse should set IV pump to
deliver how many mL/hr? (Round to whole number).
Give this one a try later!
