Which interventions should the nurse include to prevent a catheter-related bloodstream infection? (Select all that apply)

Cleanse the preferred site with alcohol and let it dry completely before insertion.

Ask everyone in the room to wear a surgical mask during the procedure.

Plan to complete a sterile dressing change on the device every day.

Use minimal client draping and barrier precautions, as blood loss is minimal.

Answer and Explanation

Correct Answer : A,C

Choice A reason: Cleansing with alcohol and allowing it to dry kills surface bacteria, reducing infection risk. Drying prevents residual alcohol from irritating skin or diluting the antiseptic effect, ensuring a sterile insertion site.
Choice B reason: Surgical masks are not routinely required for peripheral IV insertion, as the risk of airborne contamination is low. Standard sterile technique, including site cleansing and gloves, is sufficient to prevent bloodstream infections.
Choice C reason: Daily sterile dressing changes maintain a clean insertion site, preventing bacterial colonization. Transparent dressings allow monitoring while protecting against contamination, reducing the risk of catheter-related bloodstream infections in prolonged IV therapy.
Choice D reason: Minimal draping increases infection risk, as it fails to maintain a sterile field. Full barrier precautions, including drapes and gloves, are essential to prevent bacterial entry into the bloodstream during catheter insertion.

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Correct Answer is B

Explanation

Choice A reason: Beginning the infusion before confirming placement risks complications, as the catheter may be misplaced in an artery or tissue, causing emboli or tissue damage. X-ray confirmation ensures safe administration through the central line.
Choice B reason: An x-ray confirms the central venous catheter’s tip is correctly positioned in the superior vena cava, preventing complications like pneumothorax, arterial puncture, or infusion into tissues, which could lead to serious adverse effects.
Choice C reason: Checking medication calculations is unrelated to catheter placement. Ensuring proper placement via x-ray is critical to prevent infusion errors, such as delivering medication into an incorrect vessel or tissue space.
Choice D reason: Verifying solution compatibility is important but secondary to confirming catheter placement. Incorrect placement can cause infusion into non-vascular spaces, leading to tissue damage or ineffective therapy, making x-ray confirmation the priority.

A. Chart the procedure in the client’s medical record. B. Monitor the client until the pain subsides. C. Verify blood product identification. D. Review the client’s record for known allergies.

Correct Answer is C

Explanation

Choice A reason: Charting is important for documentation but not the priority before transfusion. Verifying blood product identification prevents life-threatening transfusion reactions, such as hemolytic reactions, which can occur from mismatched blood types.
Choice B reason: Monitoring for pain is irrelevant, as pain is not a primary concern during transfusion initiation. Ensuring correct blood product identification prevents severe reactions like hemolysis, which can cause organ damage or death.
Choice C reason: Verifying blood product identification ensures the correct blood type is administered, preventing hemolytic transfusion reactions. Mismatched blood can cause immune-mediated hemolysis, leading to severe complications, including renal failure or shock, making this the priority.
Choice D reason: Reviewing allergies is important but secondary to verifying blood product identification. Allergic reactions are less severe than hemolytic reactions from mismatched blood, which pose immediate life-threatening risks during transfusion.

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Which interventions should the nurse include to prevent a catheter-related bloodstream infection? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next?

Correct Answer is B

Explanation

Before administering a blood transfusion, which action by the nurse is most important?

Correct Answer is C

Explanation

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When performing an IV insertion on an adult, which actions will the nurse take? (Select all that apply)

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