When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

Position the client's head facing away from the site.

Aspirate for the presence of a blood return.

Prepare a saline flush in a three mL syringe.

Initiate an infusion of 0.9% normal saline solution.

Answer and Explanation

The Correct Answer is B

A. Position the client's head facing away from the site: While positioning can help reduce the risk of infection or discomfort, it does not ensure that the catheter is patent or safe for medication administration.

B. Aspirate for the presence of a blood return: Confirming blood return verifies that the central venous catheter is patent and correctly positioned in the bloodstream. This is a critical safety step before administering intravenous medications to prevent extravasation or ineffective delivery.

C. Prepare a saline flush in a three mL syringe: While flushing the catheter is important for maintaining patency, the nurse must first confirm the catheter is patent by aspirating for blood return before flushing or administering medication.

D. Initiate an infusion of 0.9% normal saline solution: Starting a continuous infusion is not necessary solely for medication administration. The priority is confirming patency and safe access, after which flushing and medication administration can proceed.

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Correct Answer is D

Explanation

A. Palpate flank area: Flank assessment may help detect kidney tenderness or infection but is not the primary focus for routine suprapubic catheter care unless complications are suspected.

B. Assess perineal area: The suprapubic catheter bypasses the perineal route, so routine perineal assessment is less critical for catheter management, though general hygiene remains important.

C. Measure abdominal girth: Abdominal girth measurement is useful for detecting ascites or abdominal distention but is not directly relevant to monitoring a suprapubic catheter.

D. Observe insertion site: Regular inspection of the catheter insertion site is essential to detect signs of infection, leakage, irritation, or improper placement. This assessment helps ensure catheter function and prevents complications, making it the priority during home visits.

A. Reduced pulse distal to injury B. Decreased range of motion C. Coolness of skin D. Pain with movement E. 1+ strength in left upper extremity

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

Reduced pulse distal to injury: A humeral fracture can damage surrounding vasculature, especially the brachial artery, leading to compromised circulation. This results in weak or absent distal pulses, which requires urgent evaluation for possible neurovascular compromise.

• Decreased range of motion: Both rotator cuff injury and humeral fracture commonly cause impaired shoulder mobility. A rotator cuff tear limits abduction and overhead activities, while a fracture mechanically restricts movement due to pain, swelling, or bone displacement.

• Coolness of skin: A humeral fracture can impair blood flow by compressing or injuring vessels, producing ischemic changes such as cool skin. This finding signals inadequate perfusion, which can progress to serious complications if untreated.

• Pain with movement: Both a rotator cuff tear and humeral fracture are associated with pain on movement. In a tear, the pain stems from tendon injury and inflammation, while in a fracture, bone disruption and soft tissue trauma intensify pain when the joint is moved.

• 1+ strength in left upper extremity: Weakness in the affected arm is more typical of rotator cuff injury, as tendon disruption limits muscular function and reduces lifting ability. This differs from fracture-related pain, where strength may be preserved but restricted by pain.

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When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is D

Explanation

Patient Data <pre> Exhibits <p>For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.</p>

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

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