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.
Use clean technique when changing the catheter dressing.
Place the client in Sims' position for catheter insertion.
The Correct Answer is B
When a central venous catheter (CVC) is inserted, it is essential to confirm proper catheter placement to ensure safe and effective administration of TPN and other medications. A chest x-ray is the gold standard method to verify the correct positioning of the CVC tip. It helps determine if the catheter is appropriately positioned in the superior vena cava or another desired location, which minimizes the risk of complications such as pneumothorax or improper medication delivery.
The other options listed are not appropriate actions for the nurse to take in this situation:
- Verifying the amount of TPN solution the client is receiving every 4 hours is a task related to ongoing monitoring of TPN administration, but it is not directly related to the preparation of the client for CVC insertion.
- Using clean technique when changing the catheter dressing is not appropriate for CVC insertion. Sterile technique is required during the insertion of a CVC to minimize the risk of infection.
- Placing the client in Sims' position is not the appropriate position for CVC insertion. The client is typically placed in a supine or Trendelenburg position during the procedure to facilitate access to the central venous system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Elevating the head of the bed while sleeping is a recommended strategy for managing GERD (gastroesophageal reflux disease). By raising the head of the bed, gravity helps to prevent stomach acid from flowing back into the esophagus, reducing the likelihood of acid reflux and associated symptoms.
"You should eat three large meals and two snacks per day" is not recommended for GERD management. Instead, it is advised to have smaller, more frequent meals throughout the day to reduce the pressure on the stomach and minimize the likelihood of acid reflux.
"You should lay down for 1 hour following a meal" is not recommended for GERD management. It is advised to avoid lying down immediately after meals, as this can increase the risk of acid reflux. It is generally recommended to wait at least 2 to 3 hours before lying down.
"You should only drink 2 cups of coffee per day" is a specific recommendation related to caffeine intake, which can potentially trigger or worsen GERD symptoms in some individuals. However, this statement alone does not encompass the comprehensive dietary recommendations for managing GERD.
Correct Answer is A
Explanation
Dark red urine following a transurethral resection of the prostate (TURP) can indicate active bleeding or hematoma formation. It is important to notify the provider because further assessment and intervention may be necessary to address the source of the bleeding and prevent complications.
Frequent urge to urinate is expected after a TURP procedure as the bladder recovers and adapts to the changes. This is not a concerning finding and does not require immediate reporting to the provider.
Urine output of 300 mL over 8 hours can be considered adequate, especially in the early postoperative period. The nurse should continue to monitor the client's urinary output, but this finding does not require immediate reporting.
Occasional small clots in the urine can be expected after a TURP procedure due to the healing process and sloughing of tissue. However, if the clots become large or obstructive, or if there is a sudden increase in the frequency of clots, it should be reported to the provider.
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