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 D

Explanation

A.Having a health care proxy does not mean that the individual relinquishes their right to make their own decisions. A health care proxy is designated to make decisions on behalf of the individual when they are unable to do so, but the individual retains the right to make decisions if they are capable.

B.Having a health care proxy does not eliminate the need for a living will. A living will outline the individual's specific wishes regarding medical treatments and end-of-life care, while a health care proxy designates a person to make decisions on their behalf. Both documents serve different purposes and can work together to ensure the individual's wishes are respected.

C.A health care proxy designee is typically empowered to make medical decisions on your behalf, including signing consent forms if necessary. This is one of the primary roles of a health care proxy – to act in your best interests when you are unable to make decisions yourself, including signing forms for procedures or treatments.

D.The individual has the choice to name any person as their health care proxy designee, regardless of their relationship. It is important to choose someone who understands the individual's wishes and can make decisions in their best interest. The decision of whom to name as the health care proxy designee is personal and should be based on trust and understanding.

A. Weight loss B. Diarrhea C. Insomnia D. Diaphoresis

Correct Answer is C

Explanation

Insomnia refers to the difficulty in falling asleep or staying asleep, leading to sleep disturbances. It is a frequently reported symptom during the initial phase of nicotine withdrawal.

While weight loss can be associated with smoking cessation due to changes in metabolism, it is not a direct manifestation of nicotine withdrawal. Similarly, diarrhea is not a commonly reported symptom of nicotine withdrawal.

Diaphoresis, which refers to excessive sweating, can occur in some individuals during nicotine withdrawal, but it is not as commonly observed as insomnia. It is worth noting that different individuals may experience varying symptoms during nicotine withdrawal, and the intensity and duration of these symptoms can also differ.

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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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