A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?

Verify the amount of TPN solution the client is receiving every 4 hr.

Prepare the client for a chest x-ray to verify catheter placement.

Place the client in Sims' position for catheter insertion.

Use a clean technique when changing the catheter dressing.

Answer and Explanation

The Correct Answer is B

A.   Incorrect. Verifying the TPN solution amount is not directly related to preparing for central venous catheter insertion.
B.   Correct. Chest X-rays are typically done after central venous catheter insertion to confirm proper catheter placement.
C.   Incorrect. Sims' position is not the appropriate position for central venous catheter insertion.
The Trendelenburg position is commonly used for this purpose.
D.   Incorrect. Sterile technique, not clean technique, is used for changing the catheter dressing to prevent infection.

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Correct Answer is ["B","C"]

Explanation

A. Not indicated and could lead to complications.

B. The client reports abdominal cramping and a small, hard, painful bowel movement. A sit bath can help provide relief and comfort to the perineal area, which can be beneficial after experiencing bowel discomfort.
C. The client reports pain and has had a small, hard, painful bowel movement. Encouraging oral fluid intake helps prevent dehydration and can soften the stool, making it easier to pass and reducing the risk of constipation.
D. Not necessary or appropriate without further assessment.

E. Not necessary and may not provide any additional benefit in this context.

A. Instruct the client to hold the drainage bag at waist height when ambulating. B. Collect a sterile specimen from the urinary drainage bag. C. Secure the tubing with adhesive tape to the lower abdomen. D. Coil the tubing on the bed above the collection bag.

Correct Answer is C

Explanation

A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
B. Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
C. Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D. Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.

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A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C"]

Explanation

A nurse is caring for a client who has an Indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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