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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Lymphedema is a contraindication to acupuncture because it increases the risk of infection and worsens the swelling. Acupuncture should not be performed on an oedematous limb at risk of lymphoedema.

The other options are not contraindications to acupuncture.

A. Increased heart rate B. Generalized abdominal pain C. Cloudy effluent D. Fever

Correct Answer is C

Explanation

This is because peritonitis is an infection of the peritoneal cavity that can occur as a complication of peritoneal dialysis. Peritonitis can cause inflammation and irritation of the peritoneum, which can lead to cloudy or milky appearance of the dialysate fluid that drains out of the abdomen (also known as effluent). Cloudy effluent is often the first and most reliable sign of peritonitis in peritoneal dialysis patients. Other signs and symptoms of peritonitis may include increased heart rate, generalized abdominal pain, fever, nausea, vomiting, loss of appetite, and malaise.

The nurse should instruct the client and his partner to inspect the effluent for clarity every time they perform an exchange and to report any changes to their health care provider immediately. The nurse should also teach them how to prevent peritonitis by following strict aseptic technique when handlingcatheters and supplies, washing hands before and after each exchange, wearing a mask during exchanges, and storing supplies in a clean and dry place.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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