A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?
Instruct the client to cough as the catheter is inserted.
Place the head of the client's bed lower than the foot.
Cleanse the site with a hydrogen peroxide solution.
Confirm the correct position of the line by obtaining a blood sample.
The Correct Answer is D
The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should expect disequilibrium with movement if the client has impaired function of the vestibulocochlear nerve, as this nerve is responsible for hearing and balance. Deviation of the tongue from midline indicates impairment of the hypoglossal nerve (cranial nerve XII), loss of peripheral vision indicates impairment of the optic nerve (cranial nerve II), and inability to smell indicates impairment of the olfactory nerve (cranial nerve I).
Correct Answer is B
Explanation
Choice a.This response may come across as challenging or confrontational. While the nurse is asking for more information, the phrasing could inadvertently put the client on the defensive. It doesn't validate the client's feelings and may not encourage a productive dialogue.
- Choice b. “Suggesting peer support or mentorship from someone who has gone through a similar experience could be beneficial in some situations, as it may help the client feel less isolated.
- Choice c. “Most people can adjust following this surgery.” may be true, but it does not acknowledge the client’s individual experience and feelings. It may also sound dismissive or minimizing of the client’s challenges.
- Choice d. “You are upset. We can talk about this later.” may be intended to give the client some space, but it does not convey empathy or support. It may also make the client feel rejected or ignored.
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