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

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.

A. A client who has dehydration with a urine output of 40 mL/hr. B. A client who has cancer and reports pain as 4 on a scale of 0 to 10. C. A client who has asthma and a respiratory rate of 40/min. D. A client who has diabetes mellitus and a fasting blood glucose of 100 mg/dL.

Correct Answer is C

Explanation

Choice A rationale:

Dehydration is a serious condition, and a urine output of 40 mL/hr is indicative of decreased renal perfusion and potential renal failure. However, this situation does not require immediate intervention compared to other choices.

Choice B rationale:

Pain management is important, and a pain score of 4 out of 10 indicates mild to moderate pain. While addressing pain is essential for the client's comfort, it is not an immediate priority compared to the situation presented in another choice.

Choice C rationale:

(Correct Choice) A respiratory rate of 40 breaths per minute in a client with asthma indicates severe respiratory distress. This client is at risk of respiratory failure and requires immediate assessment and intervention.

Choice D rationale:

A fasting blood glucose of 100 mg/dL in a client with diabetes mellitus is within a normal range and does not require immediate attention when compared to the urgent situation in another choice.

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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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