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 A

Explanation

A. Correct. The plantar Babinski reflex is elicited by stroking the sole of the foot along the lateral aspect, from the heel to the ball of the foot. The nurse's instruction to the client is accurate.
B. Tapping the knee is related to the knee jerk reflex, not the Babinski reflex.
C. Tapping the back of the heel does not elicit the plantar Babinski reflex.
D. Testing elbow extension is unrelated to the Babinski reflex.

A. The client can shower with the cast after 24 hr. B. The client's extremity should be elevated after the cast is applied. C. The client should use a hair dryer in a warm setting to relieve itching inside the cast. D. The client should keep the cast covered until it is dry.

Correct Answer is B

Explanation

A. Incorrect. Plaster casts are not waterproof and can become weakened if exposed to moisture, so showering with the cast is generally not recommended.
B. Correct. Elevating the extremity can help reduce swelling and promote comfort after the cast is applied.
C. Incorrect. Using a hair dryer inside the cast can cause burns and is not recommended for relieving itching.
D. Incorrect. Keeping the cast covered is not necessary, and covering it can trap moisture, potentially causing skin problems.

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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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