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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client takes ibuprofen for headaches. NSAIDs such as ibuprofen can cause gastrointestinal bleeding, which can result in a false positive result on a fecal occult blood test.
Option A is incorrect because breast cancer is not associated with false-positive fecal occult blood results.
Option C is incorrect because citrus juice does not affect the fecal occult blood test.
Option D is incorrect because a hemorrhoidectomy is not associated with false-positive fecal occult blood results.
Reasons why the other options are not answered:
Option A: Breast cancer is not associated with false-positive fecal occult blood results.
Option C: Citrus juice does not affect the fecal occult blood test.
Option D: A hemorrhoidectomy is not associated with false-positive fecal occult blood results.
Correct Answer is A
Explanation
A change in pupil size can indicate an increase in intracranial pressure, which can lead to a life-threatening situation. The nurse should immediately report this finding to the provider.
Choice B is incorrect because difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice C is incorrect because inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice D is incorrect because right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice B: Difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice C: Inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice D: Right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
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