Week 5 Post-Lecture
The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement? A. Chest x-ray B. Withdrawing blood to ensure patency C. Flushing the line with heparin D. Chest fluoroscopy The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.
A. Chest x-ray The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.
A primary health care provider prescribes total parenteral nutrition for a client with cancer of the pancreas. A central venous access device is inserted. What does the nurse identify as the most important reason for using this type of access? A. The amount of blood in a major vein helps to dilute the solution. B. The chance of the infusion infiltrating is decreased. C. Infection is uncommon. D. It permits free use of the hands.
A. The amount of blood in a major vein helps to dilute the solution. Unless diluted, the highly concentrated solution can cause vein irritation or occlusion. Although it permits free use of the hands, this is not the primary reason for a central line. Infection can occur at any invasive site and requires diligent care to avoid this complication. The chance of the infusion infiltration decreasing is not the primary reason, although the infusion at this site is more secure than a peripheral site and promotes free use of the hands.
A primary health care provider prescribes 1000 mL total parenteral nutrition (TPN) to be infused over 12 hours via a central venous access device. What is most important for the nurse to obtain when preparing the equipment? A. A set of hemostats to be taped at the bedside B. An infusion pump C. An infusion set delivering 60 gtts/mL D. A steady IV pole
B. An infusion pump An infusion pump should be administered in a continuous and uniform infusion to prevent hyperosmolar diuresis. A steady IV pole is true for any intravenous infusion; this is not unique to total parenteral nutrition. Also, infusion pumps can be placed on the bedside table. The tubing set should be specific for the type of infusion pump. Hemostats (clamps) are not necessary when administering total parenteral nutrition; an infusion pump should be used.
A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? A. Fluid intake below 500 mL B. Small, frequent feeding schedule C. Low-residue, bland diet D. Low-protein, high-carbohydrate diet
B. Small, frequent feeding schedule Small feedings reduce the amount of bulk passing into the jejunum and therefore reduce the fluid that shifts into the jejunum. Although a diet high in roughage may be avoided, a low-residue, bland diet is not necessary. Total fluid intake does not have to be restricted; however, fluids should not be taken immediately before, during, or after a meal because they promote rapid stomach emptying. Concentrated sweets pass rapidly out of the stomach and increase fluid shifts; the diet should be low in carbohydrates. Relatively high protein is needed to promote tissue repair.
The nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? Select all that apply. A. "I will eat a low-protein, high-carbohydrate diet." B. "I will eat a bland diet." C. "I will eat small, frequent meals instead of three large meals a day." D. "I will avoid artificially-sweetened foods." E. "I will not drink fluids when I eat meals."
C. "I will eat small, frequent meals instead of three large meals a day." D. "I will avoid artificially-sweetened foods." E. "I will not drink fluids when I eat meals." Total fluid intake does not have to be restricted; however, fluids should not be taken immediately before, during, or after a meal because they promote rapid stomach emptying. It is safe to take fluids before or after meals. Concentrated sweets pass rapidly out of the stomach and increase fluid shift and should be avoided. Dumping syndrome after gastric surgery is managed by nutrition changes that include decreasing the amount of food taken at one time. Small feedings reduce the amount of bulk passing into the jejunum and therefore reduce the fluid that shifts into the jejunum. A bland diet is not necessary. The diet should be low to moderate in carbohydrates, high in protein, and high in fat to promote tissue repair and provide energy.
A patient is being weaned from TPN and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hr. The nurse anticipates that which prescription regarding the TPN solution will accompany the diet prescription? A. Start 0.9% NS at 25 mL/hr B. Discontinue the TPN C. Decrease the TPN rate to 50 mL/hr D. Continue the current infusion rate for TPN
C. Decrease the TPN rate to 50 mL/hr
The nurse is caring for a client who has an implanted port and is receiving intravenous fluids. To decrease the risk of infection, the nurse should change the noncoring needle how often? A. Every 5 days B. Every 3 days C. Every 7 days D. Every 9 days
C. Every 7 days Best practice guidelines indicate that noncoring needles be changed at least every 7 days to decrease risk of infection. Changing a noncoring needle every 3 to 5 days is too frequent and increases the risk for infection as well as client discomfort. Changing a noncoring needle every 9 days increases the risk of infection due to the prolonged length of time the needle is in place.
A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take? A. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. B. Discontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready. C. Perform a finger stick glucose test and call the primary healthcare provider with the results. D. Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.
C. Perform a finger stick glucose test and call the primary healthcare provider with the results. Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse should infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. After beginning an infusion of 10% dextrose, the nurse may perform a finger stick glucose test and notify the healthcare provider if the results are abnormal. Discontinuing the infusion and flushing the line until the next TPN bag is ready is not recommended. Starting an infusion of 5% dextrose at keep vein open (KVO) until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless there is a negative client outcome that results.
To begin the administration of total parenteral nutrition (TPN), a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing action? A. Draw a blood sample to assess blood glucose level. B. Obtain a chest x-ray to determine placement. C. Assessing the right upper extremity for a neurologic deficit D. Auscultate the lungs to evaluate breath sounds.
D. Auscultate the lungs to evaluate breath sounds. The most significant and life-threatening complication of insertion of a subclavian catheter is a pneumothorax because of the proximity of the subclavian vein and the apex of the upper lobe of the lung; a client's respiratory status always is the priority. Although a chest x-ray may be done before TPN is begun, it is not the priority immediately after insertion of the catheter. A baseline blood glucose level should be obtained before insertion of the catheter. After TPN is started, routine monitoring of blood glucose levels is important. Although assessing for a neurologic deficit should be done eventually, it is not the priority at this time.
A client is to receive total parenteral nutrition (TPN) via a central venous access device/catheter. What information about this treatment would the nurse recognize as accurate? A. Catheter placement must be confirmed by fluoroscopy before the TPN is initiated. B. The client will experience a moderate amount of pain during the procedure. C. The jugular vein is the most commonly used catheter insertion site. D. The TPN may be administered intermittently rather than continuously.
D. The TPN may be administered intermittently rather than continuously. Although the central venous catheter remains in situ, total parenteral nutrition does not have to infuse continuously. Continuous versus intermittent administration depends on the health care provider's prescription. Placement of the tube after the procedure is verified by x-ray, not fluoroscopy. The subclavian veins are used most often; the jugular vein is too close to hair-growing areas, which increases the possibility of sepsis, and neck movements may interfere with maintaining placement of the catheter. Although a feeling of pressure may be experienced, it is not a painful procedure.
