Question

Please answer and give rationale

1. A nurse i preparing to administer a medication to a client through nontunneled percutaneous central venous catheter. Which of the following actions should the nurse take?

a. apply a local anesthetic to the skin

b. put on sterile gloves

c. flush the catheter with 10 mL of 0.9% sodium chloride

d. close the inline clamp

2. A nurse is assessing the incision of a client who is 5 days postoperative. The nurse should notify the provider when the assessment reveals whoch of the foloowing

a. edema at the sutures

b. bruising at the wound site

c. tenderness near the wound site

d. serosanguineous drainage from the incision

3. A nurse is caring for a client who has an endotracheal tube Which of the following action should the nurse take to verify placement?

a. deflate the cuff to check for tube placement

b. document the tube length where it passes the chin

c. observe for symmetry of the chest expansion

d. place the client's had and neck in a flexed position

4. A nurse is caring for a client following application of an external fixator for a tibial fracture 6 hr ago. Which of the the following action should the nurse take?

a. adjust the clamps on the fixator frame

b. palpate the dorsalis pedis pulse

c. wrap sterile gauze on the sharp point of the pins

d. maintain affected extremity in a dependent posotion

Answer 1

1. A nurse i preparing to administer a medication to a client through nontunneled percutaneous central venous catheter. Which of the following actions should the nurse take?

Non-tunneled Central Venous Catheters. Non-tunneled catheters are used for short term therapy and in emergent situations.

Option A and D do not have any role here

Option A. apply a local anesthetic to the skin

This is a medication administration procedure so need of any local anesthetic, it is needed only in catheter insertion.

Option D close the inline clamp

Because it is a medication administration procedure we need to open the inline clamp

so in this procedure

option B following option C is applicable

Option B The rationale behind this is any incisional procedure or care on incisional procedure wearing of surgical gloves is mandatory to prevent infection.

Option C the rationale behind this is to lumens should be flushed with 10 ml of 0.9% Normal Saline to check patency of lumens prior to the use of the catheter.

2. A nurse is assessing the incision of a client who is 5 days postoperative. The nurse should notify the provider when the assessment reveals which of the following

Option D is the confirm sign of surgical wound incision

and when it comes to the next sign is option A) edema.and Option B) Bruising (Redness)

Option C (Tenderness) is not the sign of surgical wound infection but pain is the symptom of surgical wound infection.

So the nurse should report to the provider if the symptom in the option A, B and D Present in the patient wound site also if the the fever present.

3. A nurse is caring for a client who has an endotracheal tube Which of the following action should the nurse take to verify placement?

The optimal placement for the endotracheal tube is 2-3cm above the carina in adults.

Answer

b. document the tube length where it passes the chin

The tubings have readings, so it is easy to predict the presence of tube end

c. observe for symmetry of the chest expansion

the proper position of the tube results in the equal expansion of the chest

4. A nurse is caring for a client following application of an external fixator for a tibial fracture 6 hr ago. Which of the the following action should the nurse take?

Answer is

Option B and C

B) palpate the dorsalis pedis pulse

This should be done to know the blood circulation below the procedure area following area to prevent the complications of ischemia.

C) wrap sterile gauze on the sharp point of the pins

This is to be done to prevent the entry of micro-organism into the pin entry site.