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.
Use clean technique when changing the catheter dressing.
Place the client in Sims' position for catheter insertion.
The Correct Answer is B
When a central venous catheter (CVC) is inserted, it is essential to confirm proper catheter placement to ensure safe and effective administration of TPN and other medications. A chest x-ray is the gold standard method to verify the correct positioning of the CVC tip. It helps determine if the catheter is appropriately positioned in the superior vena cava or another desired location, which minimizes the risk of complications such as pneumothorax or improper medication delivery.
The other options listed are not appropriate actions for the nurse to take in this situation:
- Verifying the amount of TPN solution the client is receiving every 4 hours is a task related to ongoing monitoring of TPN administration, but it is not directly related to the preparation of the client for CVC insertion.
- Using clean technique when changing the catheter dressing is not appropriate for CVC insertion. Sterile technique is required during the insertion of a CVC to minimize the risk of infection.
- Placing the client in Sims' position is not the appropriate position for CVC insertion. The client is typically placed in a supine or Trendelenburg position during the procedure to facilitate access to the central venous system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Fidelity, also known as loyalty or faithfulness, refers to the nurse's commitment to keeping promises and fulfilling their responsibilities to the client. By promising to walk with the client in the outdoor courtyard each day, the nurse is demonstrating fidelity by maintaining their commitment to the client's well-being and providing the support needed to alleviate anxiety.
Autonomy refers to the client's right to make decisions about their own care and treatment. While the nurse's promise supports the client's autonomy by accommodating their preference for exercising in the courtyard, it is not the principle being demonstrated by the nurse.
Justice refers to fairness and equality in healthcare, ensuring equitable treatment and distribution of resources. While justice is an important ethical principle, it is not directly applicable in this situation.
Nonmaleficence is the principle of doing no harm and taking actions to prevent harm to the client. While the nurse's promise of walking with the client aligns with the goal of reducing anxiety, it is not specifically related to preventing harm.
Correct Answer is B
Explanation
When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. By measuring the client's vital signs, the nurse can gather important information about the client's overall well-being, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. This assessment helps determine if there are any immediate medical concerns resulting from the fall, such as injury or shock, that require prompt attention.
The other options listed are also important but should be addressed after the initial assessment and safety measures:
- Notify the client's provider: After assessing the client's condition, if there are significant injuries or concerns identified, the nurse should promptly notify the client's provider to seek further medical guidance and intervention.
- Complete an incident report: Reporting the fall incident is an essential part of ensuring quality and safety in healthcare. However, it is not the first action the nurse should take. The immediate focus should be on the client's assessment and safety. Completing an incident report can be done once the client's immediate needs are addressed.
- Document the fall in the client's medical record: Documenting the fall in the client's medical record is important for maintaining accurate and comprehensive documentation. However, it should be done after the client's assessment, vital sign measurement, and any necessary interventions have been carried out.
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