A nurse is planning care for a client who has a central venous access device for intermittent infusions.
Which of the following actions should the nurse include in the plan of care?
Use an aseptic technique when changing the dressing.
Cleanse the site with povidone-iodine.
Flush the catheter using a 10-mL syringe.
Change the dressing every 24 hours.
The Correct Answer is A
The aseptic technique is important to prevent infection when changing the dressing of a central venous access device.
Choice B is not correct because povidone-iodine is not always the recommended cleansing agent for central venous access devices.
Choice C is not correct because a 10-mL syringe may generate too much pressure and damage the catheter.
Choice D is not correct because the dressing does not always need to be changed every 24 hours; the frequency of dressing changes depends on the type of dressing and the condition of the site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
Correct Answer is A
Explanation
Edema, or swelling in the legs, is a common symptom of venous disease.
Hair loss distal to the client’s calves (choice B) is not a typical symptom of venous vascular disorder.
Leg pain at rest (choice C) can be a symptom of peripheral vascular disease but is not specific to venous vascular disorder.
An ulcer on the tip of a toe (choice D) can be a sign of arterial vascular disorder but is not specific to venous vascular disorder.
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