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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Palpating the site for a thrill is an important action to assess the patency and function of an arteriovenous graft, which is a synthetic tube that connects an artery and a vein for hemodialysis access. A thrill is a vibration felt over the graft that indicates blood flow. The other options are incorrect because they could compromise or damage the graft.

A. WBC count 15,000/mm3 B. Sodium 130 mg/dL C. BUN 8 mg/dL D. Hematocrit 35%

Correct Answer is A

Explanation

A high WBC count (leukocytosis) indicates an inflammatory response to an infection, such as pneumonia. The nurse should expect to see this value in a client who has pneumonia and monitor the client for signs and symptoms of sepsis or systemic inflammatory response syndrome (SIRS). The other values are within normal or expected ranges for a client who has pneumonia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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