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 A
Explanation
Choice A rationale:
Addresses the family's fear directly: By demonstrating how to avoid spreading the disease, the nurse directly addresses the family's primary concern, which is the fear of contracting the infection. This proactive approach provides education and reassurance, empowering the family to make informed decisions about visitation.
Promotes understanding and adherence to precautions: Clear instruction on how to don and doff personal protective equipment, hand hygiene techniques, and other infection control measures increases the likelihood that the family will follow the precautions correctly, reducing the risk of transmission.
Empowers the family to make informed choices: By providing knowledge and skills, the nurse enables the family to feel more confident in their ability to visit safely. This sense of control can help to alleviate anxiety and promote positive coping mechanisms.
Facilitates open communication and trust: The demonstration creates an opportunity for the nurse to answer questions, address concerns, and build rapport with the family. This open dialogue can foster trust and collaboration, which are essential for effective care.
Choice B rationale:
May provide false reassurance: While it's important to offer support and hope, it's not always possible to guarantee that family members will not contract the infection. Absolute reassurances could potentially lead to complacency or disregard for precautions, increasing the risk of transmission.
Fails to address the need for education: Simply stating that the family won't get sick doesn't provide them with the knowledge and skills needed to protect themselves and the client. This lack of understanding could result in accidental transmission.
Choice C rationale:
May pressure the family: Encouraging visitation without addressing underlying fears and concerns could be perceived as pressure, leading to resentment, anxiety, or even avoidance. It's important to respect the family's decision-making process and provide support regardless of their choice.
Doesn't prioritize safety: While emotional support is important, the primary focus should be on ensuring the safety of both the client and the family. Encouraging visitation without proper education and precautions could compromise safety.
Choice D rationale:
Focuses on compliance rather than understanding: Informing the family about legal mandates may come across as authoritarian and could potentially increase anxiety or resistance. It's more effective to focus on the rationale behind the precautions and emphasize their role in protecting both the client and the family.
Misses an opportunity to build trust: Simply stating the rules without engaging in dialogue may hinder open communication and trust-building. Taking a collaborative approach and addressing concerns can lead to better understanding and adherence to precautions.
Correct Answer is B
Explanation
Choice A rationale:
Massaging the site with scented oils is not recommended for pain relief after removal of a peripheral vascular access device. There is no evidence to support the effectiveness of scented oils in this context.
Additionally, some scented oils can be irritating to the skin, which could potentially worsen the pain, redness, and swelling.
It's crucial to use products that are specifically designed for wound care and pain management, and to follow the healthcare provider's instructions.
Choice B rationale:
Applying warm compresses to the site is an effective and recommended intervention to alleviate pain, redness, and swelling after removal of a peripheral vascular access device.
Warm compresses have the following beneficial effects:
Vasodilation: They promote blood flow to the area, which helps to reduce inflammation and pain. Muscle relaxation: The warmth helps to relax tense muscles, further easing discomfort.
Pain relief: Warmth can directly inhibit pain signals, providing a soothing sensation.
Increased circulation: Improved blood flow can help to remove inflammatory substances and promote healing. It's important to use a clean, warm compress and to apply it for 15-20 minutes at a time, several times a day.
Choice C rationale:
Topical lidocaine is a local anesthetic that can temporarily numb the skin.
While it can be used for pain relief, it's not typically the first-line intervention for pain associated with removal of a peripheral vascular access device.
Warm compresses are often preferred as they provide a more natural and non-invasive approach to pain management.
Choice D rationale:
Oral pain medication may be necessary if warm compresses do not provide adequate pain relief.
However, it's important to follow the healthcare provider's instructions regarding the type and dosage of pain medication to use.
Over-the-counter pain relievers, such as acetaminophen or ibuprofen, may be sufficient in some cases. Stronger prescription pain medication may be needed for more severe pain.
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