A nurse is caring for a client who has just had a central venous catheter placed via the right subclavian vein. Which of the following actions should the nurse take?

Place the client in the Trendelenburg position

Encourage active range of motion exercises of the right arm

Keep the client's right arm immobilized

Instruct the client to cough frequently

Answer and Explanation

The Correct Answer is C

The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.

Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.

Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.

Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.

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Correct Answer is D

Explanation

"I will try to maintain my blood pressure around 116/72." This is because maintaining blood pressure within a normal range can help prevent heart disease. Choice A is incorrect because increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heartdisease.

Choice B is incorrect because lowering, not raising, LDL cholesterol is essential in preventing heart disease.

Choice C is incorrect because exercising only twice a week for 25 minutes is not enough to prevent heart disease.

An explanation for why the other choices are not answers: A – Increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heart disease, so this is not the correct statement. B – Lowering, not raising, LDL cholesterol is essential in preventing heart disease, so this is not the correct statement. C – Exercising only twice a week for 25 minutes is not enough to prevent heart disease. Thus, this is not the correct statement.

A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter C. Tenderness at the injection site D. Palpable area of induration, greater than 10 mm (0.4 in) in diameter

Correct Answer is D

Explanation

Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.

The other choices are not correct because:

- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.

- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.

- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.

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A nurse is caring for a client who has just had a central venous catheter placed via the right subclavian vein. Which of the following actions should the nurse take?

Nursing Test Bank

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