What would be the best initial nursing actions prior to inserting an IV?

Correct Answer: C

Rationale: In the context of medical surgical nursing, the best initial nursing action prior to inserting an IV is to verify the order for IV therapy (Option C). This step is crucial as it ensures that the IV therapy is appropriate for the patient's condition and has been prescribed by the healthcare provider. Verifying the order also helps prevent medication errors and ensures patient safety. The other options are not the best initial nursing actions prior to inserting an IV. Option A, having the patient wash their hands, is important for infection control but is not directly related to the insertion of an IV. Option B, preparing the IV insertion site with povidone iodine, is a step that comes after verifying the order for IV therapy and identifying a suitable vein. It is important for maintaining asepsis during the procedure. Option D, identifying a suitable vein, is an important step in the IV insertion process, but verifying the order for IV therapy takes precedence as it ensures that the IV is necessary and appropriate for the patient. In an educational context, understanding the sequence of steps in IV therapy is essential for safe and effective patient care. Verifying the order for IV therapy is a fundamental nursing responsibility that helps prevent errors and promote positive patient outcomes. It is important for nursing students to prioritize patient safety and follow established protocols when performing procedures such as IV insertion.

Correct Answer: D

Rationale: In this scenario, the correct IV solution that may be administered with blood products is option D, 0.9% NaCl (normal saline). The rationale behind choosing 0.9% NaCl is that it is the only isotonic solution among the options provided. Isotonic solutions have a similar osmolarity to blood, which helps prevent hemolysis of red blood cells during transfusion. Normal saline is compatible with blood products and does not cause significant shifts in electrolytes, making it the safest choice in this situation. Option A, D5 and 0.45% Normal Saline, is hypotonic and can lead to hemolysis due to its lower osmolarity. Option B, Lactated Ringer's, contains calcium, which can cause coagulation when mixed with blood products. Option C, 5% dextrose in water, is hypotonic and not suitable for administering with blood products due to the risk of hemolysis. Educationally, understanding the compatibility of IV solutions with blood products is crucial for nurses caring for patients requiring transfusions. It is essential to select the appropriate IV fluid to prevent adverse reactions and ensure the safe administration of blood products. Remembering the principles of isotonicity and compatibility aids in providing optimal patient care in situations involving blood transfusions.

Correct Answer: C

Rationale: Rationale: The correct answer is C) Clipping the hair in the area. When preparing a site for IV catheter insertion, it is essential to remove excess hair to ensure proper adhesion of the dressing and to prevent contamination during the procedure. Clipping the hair with scissors is preferred over shaving or using depilatory creams because it reduces the risk of skin irritation, micro-cuts, and infections that can occur with shaving. Leaving the hair intact (option A) can increase the risk of contamination, while shaving (option B) can cause skin trauma and increase the risk of infection. Using a depilatory (option D) is not recommended as it can cause skin irritation and allergic reactions. Educational Context: In medical-surgical nursing, proper IV catheter insertion is crucial for delivering medications, fluids, and blood products to patients. Maintaining a clean and sterile insertion site is essential to prevent infections and other complications. Clipping excess hair is a standard practice before IV catheter insertion as it helps to create a clean and smooth surface for proper dressing application and reduces the risk of introducing pathogens into the bloodstream. Nurses must follow best practices to ensure patient safety and promote positive outcomes in IV therapy.

Correct Answer: C

Rationale: In medical-surgical nursing, understanding fluid and electrolyte balance is crucial for patient assessment and care. In this scenario, the correct answer is C) Inelastic skin turgor is a normal part of aging. As individuals age, the skin loses elasticity due to a decrease in collagen and elastin fibers. This natural process results in skin that is less turgid and more prone to wrinkling and sagging. Option A) is incorrect because overhydration leads to skin that is puffy and edematous, not tented. Option B) is incorrect as dehydration causes the skin to lose its elasticity and become taut, not edematous and spongy. Option D) is incorrect because normal skin turgor is not moist and boggy; it should be resilient and return quickly to its original state when pinched. Educationally, it is essential for nurses to understand the normal changes that occur with aging to differentiate between expected variations and signs of pathology. By recognizing that inelastic skin turgor is a normal part of aging, nurses can provide appropriate care and interventions tailored to the individual needs of elderly patients.

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.