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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”

Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.

Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.

Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.

Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.

A. "Does your family know that you are feeling anxious?". B. "Tell me about where you lived when you were growing up.". C. "Let's talk after I finish caring for my other clients.". D. "Why are you feeling anxious?".

Correct Answer is B

Explanation

Choice A rationale:

Inquiring whether the client's family knows about their anxiety is not directly related to addressing the client's current anxiety. The focus should be on the client's feelings and needs rather than involving the family in this particular instance.

Choice B rationale:

This choice is the most appropriate response. Asking the client to share memories from their past redirects their attention from the current anxiety-provoking situation. Discussing positive memories can help alleviate anxiety and provide comfort to the client.

Choice C rationale:

Suggesting to talk later after caring for other clients dismisses the client's immediate need for support and comfort. It's essential to address the client's anxiety promptly rather than delaying the discussion.

Choice D rationale:

Asking the client why they are feeling anxious might put them on the spot and could potentially escalate their anxiety. Instead of prompting them to explain the cause of their anxiety, the nurse should focus on providing reassurance and distraction.

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A nurse is caring for a client who has a central venous access device. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

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