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: Amniocentesis involves needle insertion through the uterine wall, which can irritate the uterus and trigger contractions, risking preterm labor at 33 weeks. Monitoring contractions is vital to detect early labor signs, enabling interventions like tocolytics to delay delivery. This protects the premature fetus, ensuring better outcomes by maintaining pregnancy until closer to term.
Choice B reason: Vomiting is not a typical amniocentesis complication. The procedure is localized to the uterus, with minimal systemic effects. Nausea may occur from anxiety, but vomiting is rare and not a priority for monitoring. Focus remains on uterine and fetal complications, like contractions or fluid leakage, which directly impact pregnancy safety and outcomes.
Choice C reason: Hypertension is not directly linked to amniocentesis. The procedure does not typically affect maternal cardiovascular function, as it’s a localized intervention. Monitoring for hypertension is more relevant for conditions like preeclampsia. Post-amniocentesis, the priority is uterine activity and fetal distress, not blood pressure, making this an irrelevant complication to monitor.
Choice D reason: Polyuria is not associated with amniocentesis, as the procedure does not impact renal function or fluid balance. The focus is on complications like contractions, bleeding, or amniotic fluid leakage, which pose direct risks to the pregnancy. Monitoring polyuria is unnecessary, as it does not reflect the procedure’s physiological effects or risks.
Correct Answer is C
Explanation
Choice A reason: A pain level of 1 on a 0-10 scale indicates well-controlled pain, which does not directly impair wound healing. Adequate pain management supports mobility and recovery, reducing stress responses that could delay healing. This finding is not a risk factor for delayed wound healing in post-surgical clients.
Choice B reason: An oxygen saturation of 92% on room air is slightly low but not critically hypoxic. Wound healing requires adequate oxygenation, but levels above 90% are generally sufficient for tissue repair. This finding alone does not significantly indicate a risk for delayed wound healing compared to nutritional deficits.
Choice C reason: An albumin level of 2.5 g/dL (normal: 3.5-5.0 g/dL) indicates malnutrition, a major risk for delayed wound healing. Albumin is essential for tissue repair, collagen synthesis, and immune function. Low levels impair fibroblast activity and wound strength, increasing infection risk and slowing recovery in post-surgical clients.
Choice D reason: A body mass index of 22 is within the normal range (18.5-24.9) and does not indicate malnutrition or obesity, both of which can impair wound healing. Normal BMI supports adequate nutritional status for tissue repair, making this finding not a risk factor for delayed wound healing.
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