The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Use aseptic technique only when accessing the injection port.

Gently flush the CVC catheter lumen with sterile saline solution.

Confirm the necessity for continued use of the CVC.

Cleanse the site and change the transparent dressing daily.

Answer and Explanation

The Correct Answer is C

Brief introduction:

Central line-associated bloodstream infections result from pathogen colonization of the catheter tip or hub. Daily assessments facilitate early catheter removal to eliminate the primary mechanical nidus for bacterial entry. Maintenance of sterile barriers is critical for preventing healthcare-acquired sepsis.

Rationale:

A. Aseptic technique is mandatory for every access event, not just specific ports. Routine scrubbing of the hub for 15 seconds prevents intraluminal contamination during medication administration or fluid changes. This action is a constant requirement rather than a specific daily bundle intervention.

B. Flushing the lumen maintains patency but does not directly address the daily infection prevention bundle. Regular pulsatile flushing prevents fibrin tail formation, which can trap bacteria. While necessary for catheter function, it is not the primary daily assessment for infection reduction.

C. Daily review of line necessity is the most effective way to prevent infection. Eliminating the vascular access device as soon as clinically possible removes the portal of entry for staphylococcal species. Clinical guidelines prioritize prompt removal over all other maintenance interventions for risk mitigation.

D. Transparent dressings should be changed every 7 days or if they become damp, loose, or soiled. Frequent dressing disruptions can actually increase the risk of introducing epidermal flora into the insertion site. Daily changes are contraindicated unless the integrity of the dressing is compromised.

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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

Rationale:

A. Fatty streak formation represents the earliest visible stage of vascular compromise. Endothelial dysfunction allows circulating monocytes to enter the intima, where they become foamy macrophages after phagocytizing oxidized lipids. This stage also involves minimal platelet aggregation at the site of the initial endothelial injury or microscopic lesion.

B. Complicated lesions occur when a stable plaque undergoes rupture or erosion. The thinning of the protective fibrous cap exposes the underlying necrotic core to the bloodstream, triggering a thrombotic cascade. This sudden formation of a thrombus can lead to acute vessel occlusion and tissue ischemia or infarction.

C. Fibrous plaques involve a significant amount of lipid accumulation sequestered deep within the arterial wall. Contrary to the choice, these lesions consist of a central core of extracellular lipids and necrotic debris covered by a firm cap. They represent a more advanced stage than the initial fatty streak.

D. Fatty streaks are generally asymptomatic and do not result in thrombus formation. These early lesions are reversible and do not cause significant mechanical obstruction of blood flow. Thrombus formation is a hallmark of the complicated lesion stage rather than the initial fatty streak.

E. Fibrous plaque formation is characterized by the development of a collagenous cap. During this stage, smooth muscle cells proliferate and produce connective tissue, creating a fibrous covering over a growing lipid pool. This process contributes to the permanent structural remodeling of the arterial wall.

F. Migration of smooth muscle cells into the intima is a key feature of the fibrous plaque stage. During the fatty streak stage, the pathology is primarily limited to macrophage infiltration and lipid uptake within the subendothelial space. The structural change involving myointimal cells occurs as the lesion matures.

A. Find outlets for more social interaction. B. Center attention on positive upbeat music. C. Practice using muscle relaxation techniques. D. Think about reasons the episodes occur.

Correct Answer is C

Explanation

Brief introduction:

Moderate anxiety involves a narrowed perceptual field where selective inattention occurs, yet individuals remain capable of learning. This physiological state triggers the sympathetic nervous system, increasing heart rate and muscle tension. Effective management requires neuromuscular intervention to reduce autonomic arousal and restore baseline homeostatic regulation during stressful episodes.

Rationale:

A. Increased social stimuli during moderate anxiety may cause sensory overload, further narrowing the focus. While social support is beneficial for long-term coping, it does not provide the immediate physiological stabilization required when anxiety levels rise or during acute perceived stress.

B. Music therapy is a supportive distraction, but it does not address the underlying somatic tension present. Upbeat tempos might inadvertently increase stimulation rather than promoting the necessary parasympathetic activation required to counteract the body's fight-or-flight response.

C. Progressive muscle relaxation directly targets physical tension and lowers autonomic arousal. By focusing on internal physical control, the client can widen their perceptual field, making this the most effective behavioral strategy for managing moderate anxiety levels.

D. Analyzing triggers is a cognitive task that is difficult during periods of moderate anxiety. Attempting deep introspection while the client is symptomatic can increase frustration and anxiety; such analysis is more appropriate during the mild anxiety or calm phase.

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The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

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Naxlex Comprehensive Predictor Exams

A client has hypertension, smokes, and has high cholesterol. Which statement(s) by the nurse correctly describe the progression of atherosclerotic lesions? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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Correct Answer is C

Explanation

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