A nurse is taking care of a patient who has just had a central venous access line inserted. What is the next step the nurse should ensure is completed?
Verify that the solution is suitable for a central line.
Double-check medication calculations with another RN.
Confirm placement with an x-ray.
Initiate the prescribed infusion via the new access.
The Correct Answer is C
Choice A rationale:
While verifying the suitability of the solution for a central line is important, it is not the immediate next step after insertion. Solutions that are incompatible with central lines can cause damage to the catheter or precipitate in the bloodstream, leading to serious complications. However, confirming placement takes priority to ensure the line is correctly positioned before any infusion is initiated.
Choice B rationale:
Double-checking medication calculations is a crucial safety measure, but it is not the most urgent step after central line insertion. Medication administration can only occur after confirming proper placement to avoid unintended infusion into incorrect sites or tissues, potentially leading to tissue damage or ineffective treatment.
Choice D rationale:
Initiating the prescribed infusion via the new access is the desired outcome, but it cannot be done before confirming placement. Infusing medications or fluids through a misplaced line can have severe consequences, such as:
Infiltration of medications into surrounding tissues, causing inflammation, pain, and potential necrosis.
Administration of medications into unintended areas, such as the pleural space or the vasculature of the head and neck, leading to potentially life-threatening complications.
Delay in the delivery of necessary medications or fluids if the line is not positioned correctly within the central venous system.
Choice C rationale:
Confirming placement with an x-ray is the essential next step to ensure the central line is in the correct position within the central venous system. This verification is crucial for several reasons:
Prevention of complications: Misplaced central lines can cause serious complications, such as pneumothorax (collapsed lung), hemothorax (blood in the pleural space), arrhythmias (irregular heartbeats), and nerve damage.
Accurate medication and fluid delivery: Proper placement ensures that medications and fluids are delivered directly into the central circulation, allowing for rapid and effective distribution throughout the body.
Safe and effective infusion: X-ray confirmation provides visual evidence of the line's position, guiding subsequent infusion practices and reducing the risk of errors.
Early identification of malposition: If the x-ray reveals a misplaced line, adjustments can be made promptly to prevent potential complications and ensure appropriate infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
It is incorrect to state that the client will not be able to bathe with a central vascular access device.
While certain precautions are necessary to keep the device dry and clean during bathing, bathing is still possible and important for maintaining hygiene.
The nurse should provide specific instructions on how to protect the device during bathing, such as using a waterproof cover or avoiding direct water contact.
Choice B rationale:
It is inaccurate to claim that there is no risk of infection associated with a central vascular access device, even when sterile technique is used during insertion.
Infection is a serious potential complication, and it's crucial to emphasize ongoing infection prevention measures to the client.
The nurse should educate the client about signs and symptoms of infection to watch for and the importance of prompt reporting to healthcare providers.
Choice C rationale:
It is not always necessary to wear a sling on the arm with the central vascular access device.
The need for a sling may depend on the type of device, the client's condition, and the healthcare provider's recommendations.
If a sling is indicated, the nurse should provide instructions on proper use and care to maintain comfort and prevent complications.
Choice D rationale:
This is the correct statement to include in the client's teaching.
Thorough cleaning of the connections prior to accessing the device is essential for preventing infection.
The client should be empowered to advocate for themselves and ensure that all providers follow proper infection control procedures.
Correct Answer is B
Explanation
Choice A rationale:
Contact inhibition is a normal mechanism that regulates cell growth. When normal cells come into contact with each other, they stop growing. This prevents uncontrolled growth and the formation of tumors.
Benign tumor cells do not typically lose contact inhibition. They still respond to contact signals from neighboring cells and stop growing when they come into contact with each other.
However, they may grow in an uncontrolled manner due to other factors, such as mutations in genes that regulate cell growth.
Choice C rationale:
Invasion is a characteristic of malignant (cancerous) tumors, not benign tumors. Malignant tumors have the ability to invade surrounding tissues and spread to other parts of the body.
Benign tumors, on the other hand, are localized and do not invade surrounding tissues. They may grow and compress nearby tissues, but they do not spread.
Choice D rationale:
Anaplasia is a term used to describe the loss of differentiation of cells in a tumor. This means that the cells no longer resemble the normal cells from which they originated.
Anaplasia is a characteristic of malignant tumors, not benign tumors. Benign tumor cells typically retain some of the characteristics of the parent cells.
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