Which location should the nurse assess prior to the insertion of a central venous access device?
The back of the hand.
Near the fourth intercostal space.
Below the sternum.
Over the subclavian vein.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
As individuals age, the kidneys often lose their ability to concentrate urine effectively due to a decrease in the number of functioning nephrons and a reduced response to antidiuretic hormone. This physiological change results in a larger volume of dilute urine being produced, which frequently leads to nocturia, the need to urinate multiple times during the night. Normal urine specific gravity ranges from 1.005 to 1.030, but this may fluctuate significantly in the elderly population.
Choice B rationale
Aging is associated with a gradual loss of elasticity and muscle tone in the bladder wall. This reduction in tone decreases the total capacity of the bladder, meaning the older adult feels the urge to void more frequently even with smaller amounts of urine. This change is a normal part of the aging process and contributes to the increased frequency of urination often reported by geriatric patients. It explains why they may not be able to hold urine.
Choice C rationale
A decrease in the contractility of the detrusor muscle is a common age-related change that affects the emptying phase of micturition. When the bladder muscle cannot contract with sufficient force or duration, the bladder may not empty completely, leading to an increase in post-void residual volume. This state of urinary retention increases the risk for urinary tract infections and overflow incontinence. Normal post-void residual is generally considered to be less than 50 mL.
Choice D rationale
The statement is incorrect because aging actually leads to a decrease in pelvic floor muscle tone rather than an increase. Weakened pelvic floor muscles, often due to hormonal changes or previous physical stressors, fail to provide adequate support to the urethra and bladder neck. This loss of structural support is a primary contributor to stress incontinence in older adults. Therefore, the student mentioning an increase in tone requires further teaching to correct their understanding of anatomy.
Correct Answer is A
Explanation
Choice A rationale
Improvement in wound healing is evidenced by a reduction in size, the presence of granulation tissue, and minimal drainage. Granulation tissue is highly vascularized connective tissue that forms during the proliferative phase of wound healing, indicating that the body is successfully filling the wound gap. The pink edges suggest healthy epithelialization. These are positive clinical indicators that the physiological processes of tissue repair are functioning effectively, despite the presence of unrelated gastrointestinal symptoms.
Choice B rationale
No change would mean the wound dimensions, tissue quality, and drainage levels remain identical to the previous assessment. The description states the wound is now smaller and contains granulation tissue, which signifies a dynamic shift toward recovery. If the wound had stayed the same size with the same characteristics, it would indicate a stalled healing process. However, the visible progress in tissue architecture confirms that the wound status has transitioned from its previous state.
Choice C rationale
A complication regarding a wound would involve signs of localized infection, such as increased purulent drainage, foul odor, worsening edema, or expanding erythema. The assessment specifically notes a lack of odor or swelling and describes the drainage as minimal and serous. Because the wound is showing physiological signs of repair and lacks markers of infection or dehiscence, it cannot be categorized as a complication. The healing process is proceeding better than in the previous visit.
Choice D rationale
Deterioration would be marked by the wound becoming larger, deeper, or showing necrotic tissue such as slough or eschar. Since the nurse observed that the wound is smaller and has healthy granulation tissue, the wound is not regressing. Deterioration often involves an increase in pain and exudate, which contradicts the client's report of decreased pain and the nurse's observation of minimal drainage. The physical evidence points toward a trajectory of healing rather than a decline.
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