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 C
Explanation
A. The child develops a dry, hacking cough: This suggests ineffective clearance of secretions and may indicate a need for further intervention.
B. The child has increased nasal secretions: Nasal secretions are not directly related to the effectiveness of high-frequency chest compressions in clearing pulmonary secretions.
C. The child has increased sputum production: Increased sputum production indicates that the
treatment is effectively mobilizing and clearing mucus from the airways, which is beneficial for a child with cystic fibrosis.
D. The child develops diminished breath sounds: Diminished breath sounds could indicate a complication such as atelectasis or pneumothorax and would not be an expected finding with effective high-frequency chest compressions.
Correct Answer is C
Explanation
A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.
B. Notifying the client's provider may be necessary, but it is not the immediate priority.
C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.
D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.
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