A nurse is educating a client who is prescribed a central vascular access device and is transferring to a skilled facility for long-term treatment. Which statement should the nurse include in this client’s teaching?
“You will not be able to bathe with this vascular access device.”
“There is no risk of infection because sterile technique will be used during insertion.”
“You will need to wear a sling on your arm while the device is in place.”
“Ask all providers to thoroughly clean the connections prior to accessing the device.”
The Correct Answer is D
Choice A rationale:
It is incorrect to state that the client will not be able to bathe with a central vascular access device.
While certain precautions are necessary to keep the device dry and clean during bathing, bathing is still possible and important for maintaining hygiene.
The nurse should provide specific instructions on how to protect the device during bathing, such as using a waterproof cover or avoiding direct water contact.
Choice B rationale:
It is inaccurate to claim that there is no risk of infection associated with a central vascular access device, even when sterile technique is used during insertion.
Infection is a serious potential complication, and it's crucial to emphasize ongoing infection prevention measures to the client.
The nurse should educate the client about signs and symptoms of infection to watch for and the importance of prompt reporting to healthcare providers.
Choice C rationale:
It is not always necessary to wear a sling on the arm with the central vascular access device.
The need for a sling may depend on the type of device, the client's condition, and the healthcare provider's recommendations.
If a sling is indicated, the nurse should provide instructions on proper use and care to maintain comfort and prevent complications.
Choice D rationale:
This is the correct statement to include in the client's teaching.
Thorough cleaning of the connections prior to accessing the device is essential for preventing infection.
The client should be empowered to advocate for themselves and ensure that all providers follow proper infection control procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Prednisone is a corticosteroid that suppresses the body's natural production of cortisol. Cortisol is a hormone that is essential for life, and it plays a role in many important bodily functions, including:
Regulating blood sugar levels Maintaining blood pressure Reducing inflammation Responding to stress
When a person takes prednisone for a long period of time, their body begins to rely on the medication to provide cortisol. If the medication is stopped suddenly, the body cannot produce enough cortisol on its own, which can lead to a life-threatening condition called adrenal insufficiency.
Adrenal insufficiency can cause a variety of symptoms, including: Extreme fatigue
Weakness Dizziness Nausea Vomiting Abdominal pain Confusion
Loss of consciousness
To prevent adrenal insufficiency, it is important to taper off prednisone slowly over a period of time. This allows the body to gradually adjust to producing cortisol on its own.
Here are some additional details about why prednisone should never be discontinued abruptly: The risk of adrenal insufficiency is highest when prednisone has been taken for more than 3 weeks. The longer a person has been taking prednisone, the slower the taper should be.
It is important to follow the tapering instructions provided by the healthcare provider.
If a person experiences any symptoms of adrenal insufficiency, they should seek medical attention immediately.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale:
Elevate the head of the bed to 35-45 degrees unless contraindicated:
Promotes venous return: Elevating the head of the bed reduces venous pooling in the lower extremities and promotes venous return to the heart. This helps to improve cardiac output and reduce the risk of fluid overload.
Reduces aspiration risk: Elevating the head of the bed also helps to prevent aspiration, as it keeps the head and neck in a more upright position. This allows for better drainage of secretions and reduces the chance of them entering the lungs.
Contraindications: There are a few contraindications to elevating the head of the bed, such as severe hypotension, head injury, or spinal injury. In these cases, the potential benefits of elevation must be weighed against the risks.
Choice B rationale:
Assess Vital Signs:
Baseline assessment: It's crucial to obtain baseline vital signs before administering any IV fluid to have a reference point for comparison. This allows for early detection of any changes that may indicate fluid overload or other complications.
Monitoring fluid status: Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, provide important information about the patient's fluid status and hemodynamic stability. Changes in vital signs can signal fluid overload, dehydration, or other problems that may require intervention.
Detecting adverse reactions: Vital signs can also help to detect adverse reactions to the IV fluid, such as allergic reactions or anaphylaxis. Early identification of these reactions is essential for prompt treatment.
Choice D rationale:
Assess lung and heart sounds:
Baseline assessment: Assessing lung and heart sounds before IV fluid administration provides a baseline for comparison and helps to identify any preexisting conditions that may affect fluid tolerance.
Detecting fluid overload: Crackles in the lungs, increased heart rate, and extra heart sounds can indicate fluid overload, which can lead to pulmonary edema and heart failure.
Monitoring response to therapy: Lung and heart sounds can also be used to monitor the patient's response to IV fluid therapy. Improvement in lung sounds and heart rate can indicate a positive response to treatment.
Choice E rationale:
Obtain baseline weight:
Accurate fluid balance: Obtaining a baseline weight is essential for accurate assessment of fluid balance. It allows for tracking of fluid gains and losses and helps to prevent fluid overload or dehydration.
Monitoring fluid status: Changes in weight can reflect changes in fluid status. Weight gain can indicate fluid retention, while weight loss can suggest dehydration.
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