what is the most important nursing action when caring for a patient with a central venous catheter cvc
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?

Correct answer: B

Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.

2. A nurse is preparing to administer a medication that requires a peak and trough level. What is the nurse's priority action?

Correct answer: B

Rationale: The nurse's priority action should be to withhold the medication until the trough level is obtained. This is crucial to ensure accurate dosing based on the patient's levels. Administering the medication before the peak level is obtained (choice A) can lead to incorrect dosing. Administering the medication based on the previous trough level (choice C) may not reflect the current levels accurately. Ensuring that the medication is administered within 2 hours of the peak level (choice D) is not necessary for obtaining accurate peak and trough levels.

3. The nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for?

Correct answer: C

Rationale: When a patient is immobile, the nurse should assess for psychosocial aspects, including a loss of hope and increased risk of depression. While issues like weight loss (choice A), loss of bone mass (choice B), and loss of strength (choice D) can also occur due to immobility, the primary concern in this scenario is the patient's mental and emotional well-being, making 'Loss of hope' the correct answer.

4. A school nurse is developing a teaching plan about testicular cancer for a group of clients. Which of the following information should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C because testicles should be uniform in consistency when performing a self-exam, and any lumps or abnormalities should be reported. Choice A is incorrect as testicular self-examinations should be performed monthly, not weekly. Choice B is incorrect because the epididymis should be included in the examination. Choice D is incorrect because a warm shower helps relax the scrotum, making the exam easier to perform.

5. A nurse manager on an acute care unit is preparing a staff presentation about promoting cost-effective care. Which of the following strategies should the nurse plan to include in the presentation?

Correct answer: D

Rationale: Teaching staff proper use of PPE helps reduce the spread of infections and promotes cost-effective care.

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