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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Monitoring the infant's lymphocyte count is important in evaluating the immune function of the infant. HIV primarily affects the immune system, including lymphocytes. Monitoring the lymphocyte count helps assess the progression of the disease and the effectiveness of treatment.

Exchange transfusions are not typically used in the management of HIV. They are primarily performed in conditions like severe neonatal jaundice or blood disorders, but not for the treatment of HIV.

Granulocyte colony-stimulating factor (G-CSF) is a medication used to stimulate the production of white blood cells called granulocytes. While G-CSF can be used in certain situations, such as to counteract the side effects of certain chemotherapy drugs, it is not a standard treatment for HIV in infants.

Droplet precautions are typically implemented for infectious diseases that spread through respiratory droplets, such as influenza or respiratory syncytial virus (RSV). HIV does not spread through respiratory droplets, so initiating droplet precautions would not be necessary in the care of an infant with HIV.

A. Nervousness B. Pruritus C. Cough D. Polyuria

Correct Answer is A

Explanation

Explanation

A, Nervousness

Levothyroxine is a medication used to treat hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormones. Thyrotoxicosis, on the other hand, is a condition characterized by an excess of thyroid hormones in the body, which can occur as a side effect of levothyroxine or other thyroid medications.

Nervousness is a common symptom of thyrotoxicosis. Excess thyroid hormones can lead to increased sympathetic nervous system activity, causing symptoms like nervousness, restlessness, anxiety, and palpitations.

Pruritus (itching) in (option B) is not correct because it is not a typical manifestation of thyrotoxicosis. Itching is not directly related to thyroid hormone levels and is more likely to be associated with other conditions or medication side effects.

Cough In (option C) is not correct because it is not a typical manifestation of thyrotoxicosis. Coughing is not a symptom directly related to thyroid hormone levels and is more likely to be associated with respiratory or other conditions.

Polyuria (increased urination) in (option D) is not correct because it is not a typical manifestation of thyrotoxicosis. Polyuria is not a symptom directly related to thyroid hormone levels and is more likely to be associated with other conditions, such as diabetes or kidney problems.

If the client experiences symptoms of thyrotoxicosis, such as nervousness, palpitations, or any other concerning signs, it is essential to notify the healthcare provider promptly. The provider may need to adjust the dosage of levothyroxine or consider other treatment options to address the excess thyroid hormone levels and ensure the client's well-been

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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