A nurse is providing care for a client who has a central venous access device. Which of the following actions should the nurse take when providing site care?
Clean the insertion site with betadine.
Flush the catheter with sterile water.
Use a 5-mL syringe to flush the catheter.
Wear sterile gloves when providing site care.
The Correct Answer is D
A. Clean the insertion site with betadine: While povidone-iodine (Betadine) can be used, current guidelines recommend using chlorhexidine for central line site care because it is more effective in preventing catheter-related bloodstream infections. Using betadine is not the preferred standard of care.
B. Flush the catheter with sterile water: Central venous catheters should be flushed with sterile saline, not sterile water, to maintain patency and avoid hemolysis or electrolyte imbalance. Flushing with water can damage blood cells and the catheter.
C. Use a 5-mL syringe to flush the catheter: A minimum of a 10-mL syringe is recommended when flushing a central venous catheter because smaller syringes generate excessive pressure that can damage the catheter. Using a 5-mL syringe increases the risk of catheter rupture.
D. Wear sterile gloves when providing site care: Sterile technique is required when performing central line site care to prevent infection. Wearing sterile gloves protects the client from pathogens and is a critical step in maintaining asepsis during dressing changes and catheter maintenance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "What part of this assignment makes you upset?": This response encourages open communication, allowing the staff nurse to express specific concerns. It demonstrates active listening, validation of feelings, and promotes problem-solving in a professional and supportive manner.
B. "Let's discuss how this affects your performance improvement plan.": This response shifts the focus to evaluation or discipline rather than addressing the immediate concern. It may create defensiveness and does not validate the nurse’s feelings or allow for discussion of the assignment issue.
C. "Why are you talking to me instead of the charge nurse?": This response is dismissive and may discourage the staff nurse from voicing concerns in the future. It does not address the fairness of the assignment or explore potential solutions.
D. "You are not the only one with a heavy assignment today.": Comparing workloads minimizes the nurse’s concerns and can be perceived as unsupportive. It does not facilitate problem-solving or acknowledge the staff nurse’s feelings about the assignment.
Correct Answer is C
Explanation
A. The client's activity level: Physical activity is a modifiable risk factor because the client can increase exercise to reduce cardiovascular risk. Lifestyle changes in activity level can significantly impact heart health and recovery after a myocardial infarction.
B. The client's stress level: Stress is a modifiable risk factor as clients can employ stress-reduction techniques, counseling, or lifestyle modifications to lower cardiovascular risk. Managing stress can improve both short-term and long-term cardiac outcomes.
C. The client's race: Race is a nonmodifiable risk factor because it is inherent and cannot be changed. Certain racial and ethnic groups have a higher prevalence of cardiovascular disease due to genetic, socioeconomic, and health access factors.
D. The client's diet: Diet is a modifiable risk factor since clients can adjust their nutritional intake to reduce cholesterol, blood pressure, and overall cardiovascular risk. Nutritional counseling is often part of post-MI care to improve outcomes.
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