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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "I should lie down after my meals.": Lying down immediately after eating can worsen nausea and increase the risk of acid reflux. Clients should remain upright after meals to facilitate digestion and reduce nausea.

B. "I should avoid eating hot foods.": Avoiding hot, spicy, or strong-smelling foods can help reduce nausea and gastrointestinal discomfort. Eating bland, cool, or room-temperature foods is easier on the stomach and aligns with dietary recommendations for gastroenteritis.

C. "I should drink a caffeinated beverage one hour before a meal.": Caffeine can irritate the gastrointestinal tract and worsen nausea. Clients should avoid caffeinated beverages during episodes of gastroenteritis to prevent exacerbation of symptoms.

D. "I should increase my intake of liquids with meals.": Drinking large amounts of liquid with meals can contribute to feelings of fullness, bloating, and nausea. It is generally recommended to sip fluids between meals rather than during meals to maintain hydration without worsening symptoms.

A. Urine protein B. Report of headache C. Urine ketones D. Fetal activity E. Blood pressure

Correct Answer is ["A","B","D","E"]

Explanation

A. Urine protein: The presence of 3+ protein in the urine is abnormal and indicates significant proteinuria, which is a key sign of preeclampsia. Monitoring protein levels is essential for detecting kidney involvement and assessing maternal and fetal risk.

B. Report of headache: A severe headache unrelieved by acetaminophen in a pregnant client with elevated blood pressure is a concerning symptom of preeclampsia. It can indicate cerebral involvement and increased risk for complications such as eclampsia or stroke.

D. Fetal activity: Decreased fetal movement is an important sign of potential fetal compromise. Reduced activity may indicate fetal distress or hypoxia, requiring prompt assessment and possible intervention.

E. Blood pressure: A blood pressure reading of 162/112 mm Hg is significantly elevated and meets criteria for severe preeclampsia. Hypertension during pregnancy can lead to maternal and fetal complications, making this a critical finding to address immediately.

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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?

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