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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-1":"B"}

Explanation

The nurse should first anticipate the need to withhold oral intake then assess the client's vital signs.

Given the client’s symptoms of gnawing abdominal pain, dark tarry stools (indicating possible gastrointestinal bleeding), and pain worsened by eating, withholding oral intake is crucial to prevent further irritation or complications, especially before an endoscopic procedure. This helps avoid complications such as aspiration or exacerbating gastrointestinal issues. After ensuring that oral intake is managed appropriately, the nurse should then assess the client's vital signs to monitor for signs of hemodynamic instability or further deterioration, which can provide critical information about the client's current condition and guide further interventions.

A. Administer aspirin if the client develops a fever. B. Initiate contact precautions for the client. C. Assign the client to a negative-pressure airflow room. D. Have visitors remain at least 0.91 m (3 feet. away from the client.

Correct Answer is C

Explanation

The correct answer is choicec. Assign the client to a negative-pressure airflow room.

Choice A rationale:

Administering aspirin to a client with varicella zoster is not recommended due to the risk of Reye’s syndrome, a serious condition that can cause swelling in the liver and brain.

Choice B rationale:

While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.

Choice C rationale:

Assigning the client to a negative-pressure airflow room is crucial because it helps contain the airborne virus and prevents it from spreading to other areas of the hospital.

Choice D rationale:

Having visitors remain at least 0.91 m (3 feet) away from the client is a good practice, but it is not sufficient on its own to prevent the spread of the virus. Airborne precautions, including a negative-pressure room, are necessary.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is obtaining the client's vital signs prior to an endoscopy. Exhibits Complete the following sentence by using the list of options. The nurse should first anticipate the need to dropdown then dropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-1":"B"}

Explanation

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Correct Answer is C

Explanation

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