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
Wearing a medical identification wristband is important for children with chronic conditions such as cystic fibrosis. It helps alert others, including healthcare providers, about the child's condition in case of emergencies. The wristband can provide vital information about the child's diagnosis, treatment needs, and emergency contacts, ensuring appropriate care and timely interventions.
The other options mentioned are not appropriate or necessary for the care of a child with cystic fibrosis:
A- It is important to involve the child to an age-appropriate extent in decision-making about their treatment. Encouraging the child to participate in their own care and treatment decisions can promote their independence and self-management skills.
B- The influenza vaccine is generally recommended for children with cystic fibrosis, as they are at increased risk of respiratory infections. The vaccine helps protect against influenza and its potential complications. Therefore, the nurse should emphasize the importance of annual influenza vaccination for the child.
D- Homeschooling may not be necessary solely based on the diagnosis of cystic fibrosis. The decision regarding the child's education should be made based on their individual needs, abilities, and preferences, in consultation with the child's healthcare team and educational professionals.
Correct Answer is ["C"]
Explanation
A: The tubing should not be coiled on the bed, especially not above the collection bag, as this can interfere with the drainage of urine and increase the risk of infection.
B: The drainage bag should always be kept below the level of the bladder during ambulation to prevent backflow and reduce the risk of infection.
C: Securing the catheter tubing to the lower abdomen (for male clients) or thigh (for female clients) helps to reduce the risk of catheter displacement and trauma. Proper securing also prevents unnecessary tension on the tubing, which can cause urethral irritation.
D:A sterile specimen should be collected from the sampling port of the catheter tubing, not directly from the drainage bag, which could lead to contamination.
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