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 C
Explanation
A. Avoid oral sucrose: Oral sucrose is actually an effective nonpharmacologic pain management strategy for infants. It should not be avoided; small amounts can help reduce procedural pain during circumcision.
B. Provide IV morphine: IV morphine is not routinely indicated for circumcision in healthy term infants due to the risk of respiratory depression and because less invasive pain control methods are effective.
C. Swaddle the infant: Swaddling provides comfort and a sense of security, reducing pain and distress after circumcision. It is a safe, nonpharmacologic intervention that helps calm the infant during recovery.
D. Apply petroleum daily: Petroleum jelly is typically applied to the circumcision site to prevent the diaper from sticking and protect the healing tissue. However, it is usually applied with each diaper change, not just once daily, to ensure proper care and healing.
Correct Answer is B
Explanation
A. "Have you noticed a rash or reddening of your skin?": While skin irritation can occur with some occupational exposures, insulation installers are more commonly exposed to airborne fibers that affect the respiratory system rather than causing primary skin rashes.
B. "Do you have a cough or any breathing problems?": Insulation installers are at risk for inhaling fiberglass, asbestos, or other particles that can irritate the lungs and airways. Assessing for respiratory symptoms is essential to identify potential occupational lung disease or irritation.
C. "Have you noticed any loss of hearing or ringing in your ears?": Hearing loss and tinnitus are more relevant for workers exposed to loud noise, such as in manufacturing or construction environments with heavy machinery, rather than insulation installation specifically.
D. "Do you have any numbness or tingling in your fingers?": Numbness or tingling is usually associated with repetitive motion injuries, neuropathies, or exposure to vibrating tools. While possible, it is less directly related to the primary occupational hazards of insulation work.
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