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 B
Explanation
The client's symptoms of feeling dizzy, having a racing heart, and becoming pale while lying on their back are consistent with supine hypotension syndrome, also known as vena cava syndrome. This occurs when the weight of the uterus compresses the inferior vena cava, reducing blood flow and causing symptoms.
To address this issue, the nurse should Position the client on their left side. Lying on the left side helps relieve the pressure on the inferior vena cava and improves blood flow. This can alleviate the symptoms and prevent further complications.
Instructing the client to take a brisk walk is not appropriate in this situation, as it may exacerbate the symptoms by increasing heart rate and potentially causing further dizziness or fainting. Checking the client's temperature is not necessary in relation to these symptoms, as they are not indicative of a fever or infection.
Providing the client with a glass of orange juice may be helpful in some situations, such as if the client is experiencing hypoglycemia. However, in this case, the symptoms are likely due to supine hypotension syndrome, and repositioning the client is the priority intervention.
Correct Answer is B
Explanation
In Islam, it is customary to position the deceased's head toward Mecca, which is considered the holiest city in Islam. Mecca is the direction toward which Muslims face during prayer. Orienting the client's head toward Mecca is a sign of respect for their religious beliefs and customs.
While it is common in some cultural and religious practices for family members to stay with the deceased until burial, this may vary depending on the specific beliefs and customs of the family. It is important to respect the family's wishes and cultural practices, but it is not solely specific to Islam.
The duration of time for a family member to stay with the deceased can vary depending on cultural and religious practices, but there is no specific set duration of 8 hours in Islamic customs.
In Islam, the direction of Mecca is significant, and positioning the client's head toward Mecca is the customary practice. There is no specific requirement to position the head northward in Islamic customs.
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