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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Apply an ice pack to the client's knee: Ice application helps reduce pain and inflammation by decreasing swelling around the surgical site. Cold therapy also numbs nerve endings, providing pain relief for clients after knee arthroplasty.
B. Place pillows under the client's knee: Elevating the knee with pillows can promote flexion contractures and is generally avoided after knee arthroplasty. Instead, the leg should be kept extended and supported to encourage proper alignment and prevent complications.
C. Perform range-of-motion exercises to the client's knee: While range-of-motion exercises are important for rehabilitation, they should be done at scheduled times and not during episodes of acute pain, as they could exacerbate discomfort.
D. Gently massage the area around the client's incision: Massaging near the incision site is not recommended, as it could disrupt healing tissue, increase pain, and pose a risk of infection.
Correct Answer is C
Explanation
A. Hypertension: Elevated blood pressure is not a typical sign of bleeding. In cases of significant blood loss, compensatory mechanisms usually lead to hypotension rather than hypertension due to reduced circulating volume. A hypertensive response may occur due to pain or stress but does not indicate hemorrhage.
B. 2+ edema: Postoperative edema can occur from fluid shifts, inflammation, or IV fluid administration but is not a direct indicator of active bleeding. Bleeding is more likely to cause signs of hypovolemia, such as tachycardia or hypotension, rather than localized swelling.
C. Tachycardia: A common early sign of bleeding, as the body compensates for decreased blood volume by increasing heart rate to maintain oxygen delivery. Persistent tachycardia in a postoperative client should raise suspicion for internal bleeding, especially if accompanied by hypotension or pallor.
D. Crackles in lungs: Crackles are usually linked to fluid overload, pneumonia, or heart failure rather than bleeding. Pulmonary congestion may develop after aggressive IV fluid resuscitation, but bleeding primarily manifests with hemodynamic instability rather than respiratory symptoms.
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