A nurse is planning care for a client who has a central venous access device for intermittent infusions.
Which of the following actions should the nurse include in the plan of care?
Use an aseptic technique when changing the dressing.
Cleanse the site with povidone-iodine.
Flush the catheter using a 10-mL syringe.
Change the dressing every 24 hours.
The Correct Answer is A
The aseptic technique is important to prevent infection when changing the dressing of a central venous access device.
Choice B is not correct because povidone-iodine is not always the recommended cleansing agent for central venous access devices.
Choice C is not correct because a 10-mL syringe may generate too much pressure and damage the catheter.
Choice D is not correct because the dressing does not always need to be changed every 24 hours; the frequency of dressing changes depends on the type of dressing and the condition of the site.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
“Weight loss of.8 kg (4 Ib) in the past 24 hr.” Furosemide is a diuretic that decreases the pressure caused by excess fluid in the heart and lungs.
A weight loss of.8 kg (4 Ib) in the past 24 hr indicates that excess fluid is being removed from the body, which is a sign that the medication is effective.
Choice A is incorrect because adventitious breath sounds are a symptom of pulmonary edema, not an indication that the medication is effective.
Choice B is incorrect because furosemide has direct vasodilatory outcomes 2, which would decrease blood pressure, not elevate it.
Choice D is incorrect because there is no information found to support this statement.
Correct Answer is D
Explanation
Toxic shock syndrome (TSS) is a life-threatening condition caused by bacterial toxins.
Common symptoms include high fever, low blood pressure, headache, rapid heartbeat, nausea and vomiting, muscle pain, malaise, confusion, and rashes on the soles and palms.
A generalized rash resembling a sunburn is one of the possible signs and symptoms of TSS.
A. Elevated platelet count: TSS does not cause an elevated platelet count.
B. Decreased total bilirubin: TSS does not cause a decrease in total bilirubin levels.
C. Hypertension: TSS causes low blood pressure (hypotension), not high blood pressure (hypertension).
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