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 B

Explanation

Choice A rationale:

Increased sensitivity to touch is not an expected physiological change associated with aging. Older adults often experience decreased sensitivity to touch due to changes in nerve endings and decreased skin elasticity. This can lead to decreased sensation rather than increased sensitivity.

Choice B rationale:

Decreased peripheral circulation is an expected physiological change associated with aging. With age, blood vessels can become less elastic and more narrow, leading to reduced blood flow to the extremities. This can result in cold extremities, delayed wound healing, and increased vulnerability to skin breakdown. Nurses should assess for signs of impaired circulation in older adult clients and provide appropriate interventions to prevent complications.

Choice C rationale:

Decreased airway resistance is not an expected physiological change associated with aging. Older adults often experience increased airway resistance due to changes in lung elasticity and chest wall compliance. This can lead to decreased lung function and a higher risk of respiratory issues such as pneumonia and bronchitis.

Choice D rationale:

Increased appetite is not an expected physiological change associated with aging. In fact, many older adults experience a decrease in appetite due to factors such as changes in metabolism, decreased sense of taste and smell, and underlying health conditions. This reduced appetite can contribute to malnutrition and weight loss in the elderly population.

A. Position the client so that they are lying flat. B. Increase the client's oral fluid intake. C. Prepare the client for emergency surgery. D. Apply gentle pressure to the dressed wound.

Correct Answer is C

Explanation

Choice A rationale:

Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.

Choice B rationale:

Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.

Choice C rationale:

Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.

Choice D rationale:

Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult client. Which of the following should the nurse identify as an expected physiological change associated with aging?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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