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 A

Explanation

Bananas are one of the fruits that contain proteins similar to those found in natural rubber latex, which can cause an allergic reaction in some people. This is called latex-fruit syndrome and can also occur with other fruits such as avocado, kiwi, chestnut, and papaya. The client should inform the surgical team about their banana allergy and avoid contact with latex products such as gloves, catheters, syringes, and bandages.

A. "I will empty my bag when it is full." B. "I will take a laxative when I'm constipated." C. "I will expect my stools to be loose." D. "I will eat a high-fiber diet."

Correct Answer is C

Explanation

An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.

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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

A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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