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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale for Choice A:

Hydroxychloroquine does not typically cause hair loss as a significant side effect. While some anecdotal reports have suggested hair thinning as a possibility, it's not a well-established or common occurrence in clinical studies.

If a patient experiences hair loss while on hydroxychloroquine, it's essential to rule out other potential causes, such as underlying medical conditions, stress, or nutritional deficiencies.

It's also important to note that some individuals may have a personal predisposition to hair loss, and medications can sometimes trigger or exacerbate this issue.

Rationale for Choice B:

Hydroxychloroquine is not known to cause a burst of energy. In fact, some patients may experience fatigue or drowsiness as a side effect.

It's crucial to inform patients about potential side effects to manage expectations and promote adherence to treatment.

If a patient experiences unexpected energy changes while taking hydroxychloroquine, it's essential to report this to their healthcare provider for further evaluation.

Rationale for Choice C:

Hydroxychloroquine is generally recommended to be taken with food or milk to reduce potential gastrointestinal side effects such as nausea and vomiting.

Taking it on an empty stomach could increase the risk of these side effects, which could impact medication adherence and effectiveness.

Rationale for Choice D:

Retinal damage is the most serious adverse effect of hydroxychloroquine. It can lead to irreversible vision loss if not detected and managed early.

Patients taking hydroxychloroquine must undergo regular eye examinations to monitor for any signs of retinal toxicity.

Early detection and prompt discontinuation of the medication can often prevent permanent vision loss.

It's crucial for nurses to educate patients about this potential risk and emphasize the importance of regular eye exams.

A. Elevate the head of the bed to 35-45 degrees unless contraindicated B. Assess Vital Signs C. Recheck MD orders post infusion D. Assess lung and heart sounds E. Obtain baseline weight F. Review labs post infusion

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

Explanation

Choice A rationale:
Elevate the head of the bed to 35-45 degrees unless contraindicated:
Promotes venous return: Elevating the head of the bed reduces venous pooling in the lower extremities and promotes venous return to the heart. This helps to improve cardiac output and reduce the risk of fluid overload.
Reduces aspiration risk: Elevating the head of the bed also helps to prevent aspiration, as it keeps the head and neck in a more upright position. This allows for better drainage of secretions and reduces the chance of them entering the lungs.
Contraindications: There are a few contraindications to elevating the head of the bed, such as severe hypotension, head injury, or spinal injury. In these cases, the potential benefits of elevation must be weighed against the risks.
Choice B rationale:
Assess Vital Signs:
Baseline assessment: It's crucial to obtain baseline vital signs before administering any IV fluid to have a reference point for comparison. This allows for early detection of any changes that may indicate fluid overload or other complications.
Monitoring fluid status: Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, provide important information about the patient's fluid status and hemodynamic stability. Changes in vital signs can signal fluid overload, dehydration, or other problems that may require intervention.
Detecting adverse reactions: Vital signs can also help to detect adverse reactions to the IV fluid, such as allergic reactions or anaphylaxis. Early identification of these reactions is essential for prompt treatment.
Choice D rationale:
Assess lung and heart sounds:
Baseline assessment: Assessing lung and heart sounds before IV fluid administration provides a baseline for comparison and helps to identify any preexisting conditions that may affect fluid tolerance.
Detecting fluid overload: Crackles in the lungs, increased heart rate, and extra heart sounds can indicate fluid overload, which can lead to pulmonary edema and heart failure.
Monitoring response to therapy: Lung and heart sounds can also be used to monitor the patient's response to IV fluid therapy. Improvement in lung sounds and heart rate can indicate a positive response to treatment.
Choice E rationale:
Obtain baseline weight:
Accurate fluid balance: Obtaining a baseline weight is essential for accurate assessment of fluid balance. It allows for tracking of fluid gains and losses and helps to prevent fluid overload or dehydration.
Monitoring fluid status: Changes in weight can reflect changes in fluid status. Weight gain can indicate fluid retention, while weight loss can suggest dehydration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The primary healthcare provider prescribes Hydroxychloroquine for a patient. What information should the nurse include when discussing this medication with the patient?

Correct Answer is D

Explanation

Rationale for Choice A:

Rationale for Choice B:

Rationale for Choice C:

Rationale for Choice D:

What nursing assessments/interventions should be completed prior to administering Isotonic IV solutions? (Select all that apply)

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

Explanation

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