A nurse is taking care of a patient who has just had a central venous access line inserted. What is the next step the nurse should ensure is completed?
Verify that the solution is suitable for a central line.
Double-check medication calculations with another RN.
Confirm placement with an x-ray.
Initiate the prescribed infusion via the new access.
The Correct Answer is C
Choice A rationale:
While verifying the suitability of the solution for a central line is important, it is not the immediate next step after insertion. Solutions that are incompatible with central lines can cause damage to the catheter or precipitate in the bloodstream, leading to serious complications. However, confirming placement takes priority to ensure the line is correctly positioned before any infusion is initiated.
Choice B rationale:
Double-checking medication calculations is a crucial safety measure, but it is not the most urgent step after central line insertion. Medication administration can only occur after confirming proper placement to avoid unintended infusion into incorrect sites or tissues, potentially leading to tissue damage or ineffective treatment.
Choice D rationale:
Initiating the prescribed infusion via the new access is the desired outcome, but it cannot be done before confirming placement. Infusing medications or fluids through a misplaced line can have severe consequences, such as:
Infiltration of medications into surrounding tissues, causing inflammation, pain, and potential necrosis.
Administration of medications into unintended areas, such as the pleural space or the vasculature of the head and neck, leading to potentially life-threatening complications.
Delay in the delivery of necessary medications or fluids if the line is not positioned correctly within the central venous system.
Choice C rationale:
Confirming placement with an x-ray is the essential next step to ensure the central line is in the correct position within the central venous system. This verification is crucial for several reasons:
Prevention of complications: Misplaced central lines can cause serious complications, such as pneumothorax (collapsed lung), hemothorax (blood in the pleural space), arrhythmias (irregular heartbeats), and nerve damage.
Accurate medication and fluid delivery: Proper placement ensures that medications and fluids are delivered directly into the central circulation, allowing for rapid and effective distribution throughout the body.
Safe and effective infusion: X-ray confirmation provides visual evidence of the line's position, guiding subsequent infusion practices and reducing the risk of errors.
Early identification of malposition: If the x-ray reveals a misplaced line, adjustments can be made promptly to prevent potential complications and ensure appropriate infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Plague is a highly contagious and often fatal disease caused by the bacterium Yersinia pestis. It is transmitted to humans through the bites of infected fleas or by direct contact with infected animals or their tissues.
Plague can cause severe illness and death, even with prompt treatment. The mortality rate for untreated plague is 50-60%. Therefore, it is incorrect to state that plague produces a mild illness and generally has a low mortality rate.
Choice C rationale:
Smallpox is a highly contagious and deadly disease caused by the variola virus. It was eradicated in 1980, but there is still a risk that it could be used as a bioweapon.
Most people under the age of 40 have not been vaccinated against smallpox and therefore have no immunity to the disease. Therefore, it is incorrect to state that the majority of Americans have adequate innate immunity to smallpox.
Choice D rationale:
Safer food preparation practices have helped to decrease the incidence of foodborne illnesses.
However, foodborne illnesses can still be spread through international travel. Travelers can be exposed to contaminated food or water in other countries.
Therefore, safer food preparation practices do not eliminate the risk of foodborne illnesses being spread through international travel.
Correct Answer is B
Explanation
Choice B rationale:
Benign tumors typically grow in the wrong place or at the wrong time. This is a key distinguishing feature of benign tumors compared to normal cells. Normal cells have precise mechanisms that control their growth, ensuring they divide and multiply only when and where they are needed. Benign tumors, however, have disruptions in these regulatory mechanisms, leading to abnormal growth patterns. This means they may grow in locations where they don't belong or continue to grow even when they are no longer needed.
Here's a detailed explanation of why the other choices are incorrect:
Choice A:
Benign tumors have not lost their cellular regulation from contact inhibition. Contact inhibition is a process that stops normal cells from growing when they come into contact with other cells. Benign tumors still maintain this ability, which helps to limit their growth and prevent them from spreading to other tissues.
Choice C:
Benign tumors do not grow through invasion of other tissue. Invasion is a hallmark feature of malignant tumors (cancers). Benign tumors, on the other hand, typically grow as encapsulated masses, meaning they are surrounded by a well-defined border that separates them from surrounding tissues. They do not infiltrate or invade surrounding structures.
Choice D:
Anaplasia refers to the loss of differentiation and resemblance to the parent cells, which is a characteristic of malignant tumors, not benign tumors. Benign tumors still maintain a degree of differentiation, meaning they retain some of the characteristics of the normal cells from which they originated.
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