A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?
Instruct the client to cough as the catheter is inserted.
Place the head of the client's bed lower than the foot.
Cleanse the site with a hydrogen peroxide solution.
Confirm the correct position of the line by obtaining a blood sample.
The Correct Answer is D
The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because older adults are at increased risk of hypothermia, which is a potentially life-threatening condition that occurs when the body temperature drops below 35° C (95° F).
Hypothermia can cause confusion, drowsiness, slurred speech, slow heartbeat, shallow breathing, and loss of consciousness. Some factors that increase the risk of hypothermia in older adults are low indoor temperature, inadequate clothing, poor nutrition, chronic illness, medication use, and social isolation.
The nurse should contact the local Department of Health and Human Services for the client to help them access resources and programs that can assist them with paying their heating bills or finding alternative housing options. The nurse should also educate the client on how to prevent hypothermia by wearing warm clothing, eating well-balanced meals, drinking warm fluids, avoiding alcohol and caffeine, and staying active.
Correct Answer is C
Explanation
Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.
The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.
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