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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation:
Yogurt can be beneficial for individuals with irritable bowel syndrome (IBS) because it contains probiotics, which are live bacteria that can help promote a healthy balance of gut bacteria.
Probiotics have been shown to potentially alleviate symptoms of IBS, such as bloating, gas, and abdominal discomfort. Additionally, yogurt is a good source of calcium and protein.
B- On the other hand, "Honey" is not specifically recommended for individuals with IBS as it can be a source of fermentable carbohydrates and may contribute to symptoms such as bloating and gas in some individuals.
C- "Watermelon" is generally well-tolerated by most people and can be included in the diet of individuals with IBS, as it is low in FODMAPs (fermentable carbohydrates that can trigger IBS symptoms in some individuals).
D- "Ice cream" is not typically recommended for individuals with IBS, as it often contains high amounts of fat and lactose, which can aggravate symptoms in some individuals. However, this can vary depending on the individual's tolerance to dairy and fat.
Correct Answer is C
Explanation
Overhearing a discussion about a client's private information is a breach of confidentiality, and it is the nurse's responsibility to address the situation promptly.
While documenting the event in the client's progress notes might be necessary in some cases, it is not the initial action to take in this scenario. Similarly, submitting an incident report to the risk manager may be required for documentation purposes, but it is not the immediate action to address the breach of confidentiality.
Informing the client of the APs' actions may not be necessary unless there is evidence that the client's privacy has been compromised or if the client specifically requests to know. However, the priority is to address the issue of the conversation between the APs and ensure that confidentiality is maintained.
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