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 D
Explanation
A. "The item serving size is consistent from one manufacturer to the next.": Serving sizes can vary between different manufacturers and products. Clients should read the label carefully for the specific serving size of each item, as it is not standardized across brands.
B. “The daily values relate to a 1,500-calorie diet.": Daily values on nutrition labels are based on a 2,000-calorie diet, not 1,500 calories. Understanding this helps clients interpret percentages correctly in the context of their individual dietary needs.
C. "Food manufacturers provide nutrition information voluntarily.": Nutrition labeling is required by law for most packaged foods. It is not voluntary, and clients should understand that these labels are standardized and regulated.
D. "The ingredient with the greatest weight appears first.": Ingredients on nutrition labels are listed in descending order by weight. The first ingredient is present in the largest amount, which helps clients make informed choices about food composition.
Correct Answer is D
Explanation
A. Make referrals to support services: Referrals to social, medical, or mental health support are part of the response and recovery phases, focusing on addressing ongoing client needs after the disaster occurs, rather than planning.
B. Coordinate care in shelters: Coordinating care in shelters is an activity performed during the response phase, when the disaster has already occurred and immediate client needs must be addressed. It is not part of pre-event planning.
C. Triage injured individuals: Triage occurs during the response phase to prioritize treatment based on injury severity. This action is reactive to actual casualties and is not part of the planning phase.
D. Participate in practice drills: Engaging in disaster preparedness drills is a key component of the planning phase. Drills help identify gaps in emergency protocols, improve staff readiness, and ensure effective coordination during an actual mass casualty incident.
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