A nurse is teaching a client who is to undergo placement of a nontunneled percutaneous central venous access device. Which of the following statements should the nurse include in the teaching?
Placement of the catheter is confirmed by a CT scan.
Your head will be elevated as high as possible while the catheter is inserted.
The catheter will be flushed with saline daily.
You will need to lie flat for 24 hours after the procedure.
The Correct Answer is C
Choice A reason: Catheter placement for a nontunneled central venous access device is typically confirmed by X-ray, not a CT scan, to verify tip placement in the superior vena cava. CT scans are less common due to higher radiation and cost, making this statement inaccurate for standard practice.
Choice B reason: Elevating the head as high as possible during insertion is incorrect, as the Trendelenburg position (head down) is often used to distend veins and reduce air embolism risk. High head elevation could complicate insertion and increase complications, making this instruction inappropriate.
Choice C reason: Flushing the catheter with saline daily maintains patency, preventing clots and ensuring functionality of the nontunneled central venous access device. This is a standard care instruction, reducing infection and occlusion risks, and aligns with evidence-based protocols for central line maintenance, making it correct.
Choice D reason: Lying flat for 24 hours post-procedure is not required for nontunneled central venous catheters. Patients may need brief bed rest (e.g., 30 minutes) to prevent bleeding, but 24 hours is excessive and not evidence-based, making this instruction incorrect and overly restrictive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A WBC count of 1,300/mm³ indicates severe leukopenia, a contraindication for clozapine due to its risk of agranulocytosis. Low white cells increase infection risk, requiring immediate discontinuation or monitoring per FDA guidelines, making this the critical finding to identify.
Choice B reason: Hemoglobin of 16 g/dL is within normal range (14-18 g/dL) and does not contraindicate clozapine use. Normal hemoglobin supports adequate oxygen transport, so this finding is unremarkable and incorrect for identifying a contraindication.
Choice C reason: Fasting blood glucose of 124 mg/dL indicates mild elevation but is not a contraindication for clozapine, which may worsen glucose control. Monitoring is needed, but this level does not preclude use, making it incorrect.
Choice D reason: Platelet count of 200,000/mm³ is normal (150,000-450,000/mm³) and does not contraindicate clozapine. Normal platelets ensure proper clotting, so this finding is not a concern for clozapine administration, making it incorrect.
Correct Answer is C
Explanation
Choice A reason: Applying testosterone gel to the genital region is contraindicated, as it increases irritation and absorption variability. It should be applied to clean, dry skin on the shoulders, upper arms, or abdomen to ensure safety and efficacy, making this action incorrect and unsafe.
Choice B reason: Checking testosterone levels in 1 week is premature, as steady-state levels typically require 2-4 weeks to stabilize. Monitoring too early may yield inaccurate results, leading to improper dose adjustments. This timing is not standard, making it an incorrect instruction.
Choice C reason: Advising the client to wait 1 hour before showering or swimming ensures adequate absorption of testosterone gel through the skin. Premature water exposure can wash off the gel, reducing efficacy. This aligns with manufacturer guidelines, making it the correct action.
Choice D reason: Applying testosterone gel every other day is incorrect, as daily application maintains consistent hormone levels for hypogonadism treatment. Alternate-day dosing disrupts therapeutic levels, reducing effectiveness. Daily use is standard, making this instruction inappropriate for proper administration.
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