A nurse is preparing to administer a medication for a client through a nontunneled percutaneous central catheter. Which of the following actions should the nurse take?

Close the inline clamp.

Flush the catheter with 10 mL of 0.9% sodium chloride.

Apply a local anesthetic to the skin.

Don sterile gloves.

Answer and Explanation

The Correct Answer is B

A. Closing the inline clamp is necessary when the catheter is not in use to prevent air embolism, but it is not a required step before administering medication. The nurse should focus on flushing and checking for patency before medication administration.

B. Flushing the catheter with 10 mL of 0.9% sodium chloride before and after medication administration helps maintain patency, prevents occlusion, and ensures the catheter is functioning properly. This step is essential to avoid complications such as clot formation.

C. Applying a local anesthetic is not needed for routine medication administration through a nontunneled percutaneous central catheter. Anesthetic use is typically reserved for procedures like catheter insertion or painful dressing changes.

D. Donning sterile gloves is not required for medication administration through a central line. Clean gloves are sufficient, while sterile technique is reserved for dressing changes and catheter insertions.

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Correct Answer is D

Explanation

A. Remain at least 1 foot away from young children during treatment: Clients receiving radioactive isotope therapy should maintain a greater distance, typically at least 6 feet from children and pregnant individuals, to minimize radiation exposure.

B. Use cloth handkerchiefs instead of disposable tissues: Disposable tissues are recommended for nasal secretions because they can be discarded immediately, reducing contamination risk. Cloth handkerchiefs may retain radioactive particles, increasing exposure.

C. Use absorbent briefs for incontinence as needed: While managing incontinence is important, absorbent briefs may retain radioactive urine, increasing the risk of prolonged exposure. Frequent voiding and proper disposal of contaminated materials are preferred.

D. Flush the toilet with the lid closed three times after use: This helps minimize radiation exposure to others by ensuring radioactive waste is thoroughly diluted and flushed away, reducing contamination in the surrounding environment.

A. Apply a vest restraint daily at bedtime to prevent nighttime wandering. B. Apply soft heel protectors bilaterally while client is in bed. C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation. D. Apply mitten restraints to prevent the client from disconnecting their tube feeding.

Correct Answer is A

Explanation

A. Applying a vest restraint daily at bedtime is inappropriate because restraints should only be used as a last resort when other interventions have failed. Restraints must be ordered based on ongoing assessment rather than routine use, as they pose risks such as impaired circulation, skin breakdown, and decreased mobility.

B. Soft heel protectors help prevent pressure injuries and provide cushioning for clients at risk of skin breakdown. They are a non-restrictive intervention and do not require verification with the provider.

C. An abduction pillow helps maintain proper hip alignment and prevents dislocation in clients following hip surgery. This is a standard postoperative intervention that does not require additional verification.

D. Mitten restraints are a less restrictive alternative to wrist restraints and may be used to prevent a client from interfering with medical devices. However, their use still requires a provider's order and close monitoring to ensure patient safety.

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A nurse is preparing to administer a medication for a client through a nontunneled percutaneous central catheter. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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