Catheter-associated urinary tract infections are the most common hospital acquired infection in the United States.
What should the nurse use to help prevent infection? Select all that apply.

Choice A rationale

The back of the hand is a common site for peripheral intravenous catheters but is not an appropriate location for a central venous access device. Central lines must terminate in a large vessel, typically the superior vena cava, to handle highly concentrated or vesicant medications. Peripheral veins in the hand are too small and are located too far from the central circulation to serve as an insertion point for a standard non-peripherally inserted central catheter.

Choice B rationale

The fourth intercostal space is an anatomical landmark often used for positioning ECG leads or identifying heart sounds, but it is not a primary site for central venous access. While the tip of a central line often resides near the level of the fourth intercostal space within the superior vena cava, the actual insertion of the needle and catheter occurs higher up in the neck or chest area to access the internal jugular or subclavian veins.

Choice C rationale

The area below the sternum is generally associated with the epigastric region of the abdomen. There are no major veins in this specific superficial location suitable for the insertion of a central venous access device. Central access requires reaching deep, large-diameter veins that lead directly to the heart. Attempting access below the sternum would involve risking injury to abdominal organs and would not provide the necessary direct route to the central venous system.

Choice D rationale

The subclavian vein, located just beneath the clavicle, is one of the most common and preferred sites for the insertion of a central venous access device. It provides a direct and relatively straight route to the superior vena cava. Assessing this area involves checking for anatomical landmarks, skin integrity, and any contraindications such as previous surgeries or pacemakers. This site is favored for its lower risk of infection compared to the femoral or jugular sites.

Choice A rationale

This goal is incorrectly written because it lacks a specific timeframe for achievement. Effective outcome criteria in a nursing care plan must be SMART: specific, measurable, achievable, relevant, and time-bound. Without a deadline, the nurse cannot objectively evaluate whether the intervention was successful at a particular point in the client's recovery. While stating pain is less than or equal to 5 is measurable, the absence of a temporal component makes the goal clinically incomplete.

Choice B rationale

This is a correctly written outcome goal because it is specific and includes a clear timeframe. It identifies the subject, the measurable action using a standardized 0 to 10 pain scale, and a target window of 24 hours. Pain management is a priority postoperatively, and setting a specific threshold like 4 allows the nursing team to evaluate the effectiveness of analgesics and other comfort measures accurately within the critical early recovery period following the surgical procedure.

Choice C rationale

This goal is unrealistic and poorly defined for a postoperative client. Expecting "no pain" immediately following surgery is often unachievable due to tissue trauma and the inflammatory response. Furthermore, it lacks a timeframe for when this state should be reached. Goals must be realistic to provide a sense of progress for the patient and the healthcare team. Aiming for a manageable pain level on a numeric scale is a more evidence-based and practical nursing approach.

Choice D rationale

This goal is correctly written as it uses a measurable scale and defines a clear endpoint, which is the time of discharge. Providing a target pain level of 3 or less ensures that the patient is comfortable enough to manage activities of daily living and follow-up care at home. Using the 0 to 10 scale provides an objective way to track progress throughout the hospital stay, making it a functional part of the postoperative nursing care plan.

Choice E rationale

This statement is an intervention, not an outcome goal. An outcome goal describes a desired change in the client's status or behavior as a result of nursing care, whereas an intervention describes the actions the nurse will take. Medicating a client is something the nurse does to help reach a goal, such as reduced pain scores. Furthermore, a goal should be client-centered, focusing on the patient's response rather than the nurse's scheduled activities or tasks.