A nurse is selecting a site to insert an intravenous (IV) ...

[jon_i]

A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.)
 
  a. Check for contraindications to the extremity.
  b. Start proximally and move distally on the arm.
  c. Choose a vein with minimal curvature.
  d. Choose the patient's dominant arm.
  e. Select a vein that is rigid.
  f. Avoid areas of flexion.

Question 2

A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately?
 
  a. Blood pressure 110/60
  b. Temperature 101.3 F
  c. Poor skin turgor and pallor
  d. Heart rate of 100 beats/min

[elizabethrperez]

Answer to Question 1

ANS: A, C, F
The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such as mastectomy, AV fistula, and central line in the extremity and should be checked before initiation of IV. Avoid areas of flexion if possible. The nurse should start distally and move proximally, choosing the nondominant arm if possible. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage.

Answer to Question 2

ANS: B
A fever should be reported immediately and the blood transfusion stopped. All other assessment findings are expected. Blood is given to elevate blood pressure, improve pallor, and decrease tachycardia.