A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?
Verify the amount of TPN solution the client is receiving every 4 hr.
Prepare the client for a chest x-ray to verify catheter placement.
Place the client in Sims' position for catheter insertion.
Use a clean technique when changing the catheter dressing.
The Correct Answer is B
A. Incorrect. Verifying the TPN solution amount is not directly related to preparing for central venous catheter insertion.
B. Correct. Chest X-rays are typically done after central venous catheter insertion to confirm proper catheter placement.
C. Incorrect. Sims' position is not the appropriate position for central venous catheter insertion.
The Trendelenburg position is commonly used for this purpose.
D. Incorrect. Sterile technique, not clean technique, is used for changing the catheter dressing to prevent infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. While expressing empathy is important, the nurse should also provide practical information and support.
B. Incorrect. Delaying the discussion may leave the client feeling unheard and anxious about their upcoming chemotherapy.
C. Correct. This response acknowledges the client's concerns and provides a proactive solution to address the potential issue of hair loss. Offering information about head covering options demonstrates the nurse's support and willingness to help the client manage the physical and emotional impact of chemotherapy.
D. Incorrect. Dismissing the client's concern may contribute to their anxiety and apprehension about the chemotherapy process. It's important to address all aspects of the client's experience, including potential side effects like hair loss.
Correct Answer is ["A","B","E"]
Explanation
The nurse should write an incident report for the following events:
1. An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. This indicates a potential issue with the catheter or its proper functioning, which needs to be documented and addressed.
2. A client received an 0900 daily medication at 1000. This is a medication administration error as the medication was given later than the prescribed time. Medication errors should be reported and documented to ensure proper follow-up and prevent future occurrences.
3. A client fell when ambulating to the bathroom alone. Falls are considered significant incidents and should always be documented and reported to ensure appropriate evaluation, intervention, and prevention of future falls.
The following events do not require an incident report:
A client who has an infection refused the evening meal. While it is important to document a client's refusal of meals, it does not typically warrant an incident report unless there are specific concerns related to the client's health or safety.
A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. This may not require an incident report unless there are specific
circumstances or contraindications related to the timing of the antibiotic administration and blood collection, which need to be documented and reviewed.
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