A nurse is caring for a client who has a central venous access device. Which of the following actions should the nurse take?

Use a 5-mL syringe to flush the catheter.

Change the site dressing and stabilization device every 24 hr.

Expect blood to appear in the catheter lumen after flushing.

Use chlorhexidine solution to clean the catheter.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.

Choice B rationale:

Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.

Choice C rationale:

Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.

Choice D rationale:

This is the correct choice. Using chlorhexidine solution to clean the catheter is an evidence-based practice to prevent infection at the insertion site. Chlorhexidine has broad-spectrum antimicrobial properties and helps reduce the risk of catheter-related infections.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Chronic grief is characterized by a prolonged and ongoing sense of loss that doesn't seem to improve with time. It doesn't directly relate to maladaptive coping, which the client in the scenario is exhibiting. Chronic grief may involve a persistent yearning or sadness for the deceased, but it doesn't necessarily involve maladaptive coping strategies.

Choice B rationale:

The client's use of alcohol and controlled substances to cope with the death of their partner indicates an exaggerated grief response. Exaggerated grief involves an intense and prolonged expression of grief that may be accompanied by excessive, intense emotions and behaviors. The client's use of substances to cope is an unhealthy and maladaptive way of dealing with their grief.

Choice C rationale:

Delayed grief refers to a situation where the emotional response to a loss is significantly postponed, often resulting in a delayed and intense reaction later on. It doesn't necessarily involve maladaptive coping, as seen in the client's case.

Choice D rationale:

Masked grief occurs when the grieving person's behavior and emotional responses are influenced by the loss but not recognized as being related to it. This can lead to various physical or psychological symptoms that mask the true underlying cause, the grief. While maladaptive coping can sometimes be seen in masked grief, it doesn't directly correlate with the client's substance use in this scenario.

A. Measure the amount of aspirate in the NG tube. B. Flush the tube with 50 mL of tap water. C. Examine the color of aspirated secretions. D. Measure the pH of the client's aspirate. E. Obtain an x-ray of the client's chest and abdomen.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Measuring the amount of aspirate in the NG tube is one way to verify the placement of the tube. Aspirate should be tested for color, pH, and other characteristics to ensure proper positioning.

Choice B rationale:

Flushing the tube with tap water doesn't directly verify tube placement. This action might inadvertently introduce air into the tube, potentially leading to inaccurate assessment results.

Choice C rationale:

Examining the color of aspirated secretions is an essential step in verifying tube placement. Different colors of aspirate can indicate different anatomical locations, helping to ensure the tube is properly positioned.

Choice D rationale:

Measuring the pH of the client's aspirate is another important method to verify NG tube placement. Gastric aspirate tends to be acidic, while respiratory aspirate is usually more alkaline.

Choice E rationale:

Obtaining an x-ray of the client's chest and abdomen is a definitive method for confirming NG tube placement. It provides direct visualization of the tube's location and ensures accuracy.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has a central venous access device. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports using alcohol and controlled substances to cope with the death of their partner. The nurse should identify that maladaptive coping is an indication of which of the following types of complicated grief?

Correct Answer is B

Explanation

A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?

A nurse is planning to administer a vaginal suppository to a client. Which of the following actions should the nurse plan to take?

A nurse is admitting a client who reports having diarrhea for the past 72 hr. Which of the following actions is the nurse's priority?

A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) Communication tool?

A nurse is reviewing the client's right to refuse treatment with other members of the health care team. The nurse should identify this right as which of the following ethical principles?

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

A nurse is preparing to administer an oral opioid analgesic to a client. Which of the following actions should the nurse take when handling an unused portion of the medication after administration?