A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter (CVC). The provider writes a prescription to initiate an IV infusion of Ringer's lactate at 150 mL per hr. Prior to starting the infusion, which of the following actions should the nurse take?
Apply oxygen at 3 L/min per nasal cannula.
Review the chest x-ray report.
Flush the catheter with sterile water.
Obtain a peripheral blood glucose level.
The Correct Answer is B
A. Apply oxygen at 3 L/min per nasal cannula: While oxygenation is important, there is no
indication in the scenario that the client requires oxygen supplementation at this time. Checking oxygen saturation would be more relevant if there were respiratory concerns.
B. Review the chest x-ray report: This is the most appropriate action before initiating the IV
infusion to ensure proper placement of the central venous catheter and absence of complications such as pneumothorax or malposition.
C. Flush the catheter with sterile water: Flushing the catheter with sterile water is not necessary before starting the infusion, especially without confirming proper catheter placement through chest x-ray.
D. Obtain a peripheral blood glucose level: While monitoring blood glucose levels may be
important in certain clinical situations, it is not directly relevant to initiating an IV infusion of Ringer's lactate via a central venous catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Insisting on direct eye contact may be uncomfortable or distressing for some clients, particularly those with certain mental health conditions or cultural backgrounds. It's important to respect the client's comfort level.
B. Seating the client too far away can create a sense of distance and may hinder effective communication. A closer seating arrangement facilitates rapport and engagement.
C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially if they have concerns about their safety or autonomy.
D. Leaning in slightly when speaking to the client demonstrates attentiveness and engagement. It can also convey a sense of confidentiality and respect for the client's space.
Correct Answer is C
Explanation
A. Dependent edema is a sign of fluid overload or right-sided heart failure but is not immediately life-threatening.
B. A pericardial friction rub is a characteristic finding of pericarditis but does not indicate imminent compromise.
C. A paradoxical pulse (pulsus paradoxus) can indicate cardiac tamponade, a life-threatening complication of pericarditis. Prompt recognition and intervention are critical.
D. Substernal chest pain is a common symptom of pericarditis and should be addressed, but it is not as immediately dangerous as signs of cardiac tamponade.
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