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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Dependent personality disorder is characterized by an excessive reliance on others for decision-making and a fear of being alone or taking responsibility. Encouraging the client to be assertive helps promote their independence and self-confidence. It allows them to express their needs and preferences, make decisions, and take responsibility for their own actions. Empowering the client to be assertive can enhance their overall well-being and promote healthier relationships.

Limiting the client's social interactions may exacerbate their dependency and hinder their progress in developing more self-reliance and independent coping skills. It is important to encourage appropriate and healthy social interactions while also promoting the client's independence.

Maintaining a verbal no-harm contract with the client is a strategy more commonly used for clients at risk of self-harm or harm to others. It may not be directly applicable to the care of a client with dependent personality disorder unless there are specific safety concerns. Assuming responsibility for making the client's decisions would reinforce their dependency and enable their avoidance of taking personal responsibility. It is important to promote autonomy and support the client in making their own decisions whenever possible.

A. Caution the client to avoid a prone position while in bed. B. Keep a loose, absorbent dressing over the client's surgical site. C. Maintain abduction of the client's residual limb with a pillow. D. Encourage the client to use the overbed trapeze

Correct Answer is D

Explanation

Using the overbed trapeze helps the client strengthen their upper body and improve mobility by allowing them to independently move and reposition themselves in bed. This promotes independence in activities of daily living and reduces reliance on nursing assistance.

Cautioning the client to avoid a prone position while in bed is important for preventing pressure ulcers and maintaining proper positioning, but it does not specifically promote independence and mobility.

Keeping a loose, absorbent dressing over the surgical site is important for wound care and infection prevention, but it does not directly promote mobility or independence. Maintaining abduction of the client's residual limb with a pillow is important to prevent contractures, but it does not directly promote mobility or independence.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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