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 B
Explanation
A WBC count of 20,000/mm3 indicates infection and inflammation, which is expected in osteomyelitis. Long-term IV antibiotic therapy is a common treatment for osteomyelitis and may require a referral to avoid peripherl thrombophlebitis. Furosemide is a diuretic that may be prescribed for clients who have fluid retention or hypertension, which are not related to osteomyelitis. A HbA1c of 6% indicates good glycemic control for a client with type 2 diabetes mellitus, which can help prevent complications and infections.
Correct Answer is C
Explanation
Referred pain is pain that is felt in a location different from its source due to shared nerve pathways or central nervous system processing. A client who has pancreatitis may experience pain in the left shoulder due to irritation of the diaphragm by pancreatic enzymes or inflammation. This pain is referred from the abdominal cavity to the shoulder through the phrenic nerve.
A client who has peritonitis reports generalized abdominal pain that corresponds to the site of inflammation and infection in the peritoneum. A client who has angina reports substernal chest pain that reflects the ischemia and hypoxia of the myocardium. A client who is postoperative reports incisional pain that is caused by tissue damage and inflammation at the surgical site.
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