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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Free Nursing Study Resources

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

Explanation

Tightness in chest that radiates to left arm: Classic symptom of acute coronary syndrome (ACS), including myocardial infarction (MI). Cardiac pain is often described as pressure, squeezing, or tightness and may radiate to the left arm, jaw, or back.
Pain rated 7 on a scale of 0 to 10: Severe pain is a hallmark of an MI and suggests significant myocardial ischemia. Persistent or worsening chest pain should prompt urgent intervention.
Nausea after breakfast: Nausea and gastrointestinal discomfort can be atypical signs of an MI, particularly in individuals with diabetes. The presence of nausea alongside chest pain raises suspicion for cardiac ischemia.
Diaphoresis and shortness of breath: Sweating and dyspnea are common autonomic responses to myocardial ischemia. The body reacts to decreased cardiac output by activating the sympathetic nervous system, which results in these symptoms.
Heart rate irregular and tachycardic: Irregular tachycardia suggests possible arrhythmias, which can be triggered by myocardial ischemia and infarction. Life-threatening dysrhythmias are a significant complication of an MI.
Skin is cool to touch: Cool skin indicates decreased peripheral perfusion, which may result from reduced cardiac output due to myocardial dysfunction. It is a concerning sign of potential hemodynamic instability.

Lungs clear to auscultation in all lobes: The absence of crackles or other abnormal lung sounds suggests that pulmonary congestion is not currently present.
Bowel sounds are present in all 4 quadrants: Normal bowel sounds do not indicate any gastrointestinal pathology.
+1 pedal pulses: Diminished pulses may suggest peripheral vascular disease but are not directly indicative of an acute cardiac event.
Capillary refill less than 2 seconds: Normal capillary refill indicates adequate peripheral perfusion and does not suggest an immediate concern.

A. Inspect the mouth once each week for sores. B. Use text or pictures to communicate needs postoperatively. C. Rinse with an alcohol-based mouthwash instead of brushing. D. Increase intake of dense, high-fiber foods.

Correct Answer is B

Explanation

A. Inspect the mouth once each week for sores: Frequent oral assessments are necessary, especially after a partial glossectomy, to monitor for infection, healing complications, or signs of malignancy recurrence. Checking only once per week is insufficient for early detection of issues.

B. Use text or pictures to communicate needs postoperatively: A partial glossectomy can impair speech, making communication difficult. Using alternative methods such as writing, text, or pictures helps ensure effective communication, especially in the immediate postoperative period.

C. Rinse with an alcohol-based mouthwash instead of brushing: Alcohol-based mouthwashes can cause irritation and delay healing. Instead, gentle oral hygiene with a soft toothbrush and non-alcoholic rinses like saline or chlorhexidine is recommended to maintain cleanliness without irritation.

D. Increase intake of dense, high-fiber foods: Soft, easy-to-swallow foods are preferred after a partial glossectomy to prevent irritation and facilitate healing. Dense, high-fiber foods can be difficult to chew and may cause discomfort, increasing the risk of aspiration or delayed wound healing.

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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

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

Explanation

A nurse is providing teaching to a client who is postoperative following a partial glossectomy. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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