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.
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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Related Questions
Correct Answer is C
Explanation
A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.
B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.
C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.
D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.
Correct Answer is B
Explanation
A. Incorrect. Justice refers to fairness and equal treatment for all clients. It is not demonstrated in this scenario.
B. Correct. Fidelity, also known as "faithfulness" or "loyalty," refers to the nurse's commitment to keeping promises and maintaining trust with the client. By walking with the client as promised, the nurse is demonstrating fidelity.
C. Incorrect. Autonomy refers to the client's right to make decisions about their own care and treatment. While the nurse is respecting the client's autonomy by addressing their anxiety, the ethical principle being demonstrated here is fidelity.
D. Incorrect. Nonmaleficence refers to the duty to do no harm. While the nurse is indeed trying to prevent harm (anxiety. for the client, the ethical principle being demonstrated in this scenario is fidelity.
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