A nurse is caring for a client who has a central venous access device. Which of the following actions should the nurse take?
Use a 5-mL syringe to flush the catheter.
Change the site dressing and stabilization device every 24 hr.
Expect blood to appear in the catheter lumen after flushing.
Use chlorhexidine solution to clean the catheter.
The Correct Answer is D
Choice A rationale:
Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.
Choice B rationale:
Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.
Choice C rationale:
Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.
Choice D rationale:
This is the correct choice. Using chlorhexidine solution to clean the catheter is an evidence-based practice to prevent infection at the insertion site. Chlorhexidine has broad-spectrum antimicrobial properties and helps reduce the risk of catheter-related infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Dysrhythmia refers to irregular heart rhythms and is not associated with the carotid artery. It involves issues with the heart's electrical conduction system.
Choice B rationale:
A cardiac murmur is an abnormal sound heard during the heartbeat cycle, usually indicating turbulent blood flow across heart valves. It's not directly related to the carotid artery.
Choice C rationale:
Hypotension refers to low blood pressure, which might impact blood flow through the carotid artery but wouldn't directly cause the sound known as a bruit.
Choice D rationale:
A bruit heard while auscultating the carotid artery suggests a narrowed arterial lumen. A bruit is a whooshing or blowing sound caused by turbulent blood flow due to arterial narrowing or blockage.
Correct Answer is A
Explanation
To calculate how many milliliters (mL) of diazepam oral solution should be administered, you can use the following formula:
Dose (mL) = Desired dose (mg) / Concentration (mg/mL)
In this case, the desired dose is 2 mg, and the concentration of the diazepam oral solution is 5 mg/1 mL.
Dose (mL) = 2 mg / 5 mg/mL = 0.4 mL
So, the nurse should administer 0.4 mL of diazepam oral solution with each dose. The correct answer is:
A) 0.4 mL.
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