The nurse is caring for a client with a central venous catheter (CVC) who reports feeling
nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that
the client has a temperature of 102 F (38.8 C). Which new prescription from the health care
provider should the nurse implement first?
Administer ondansetron 4 mg IV push PRN for nausea or vomiting [3%]
1.
Document the occurrence and notify the hospital's epidemiology team [1%]
2.
Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV [13%]
3.
Obtain blood cultures and discontinue the central venous catheter [81%]
4.
Central venous catheters (CVCs) are used in the treatment of clients who require
long-term IV access or are prescribed hypertonic solutions (eg, total parenteral nutrition)
or vesicant medications. CVCs can serve as a portal of entry for bacteria, which
increases the risk of developing serious bloodstream infections. Nurses caring for
clients with CVCs should report any new or worsening signs of infection (eg, fever,
chills, erythema at the CVC site) to the health care provider because central line–related
bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis.
In response to a possible CRBSI, the CVC should be removed as soon as possible to
prevent continued exposure to the infection source. Blood cultures should be
obtained before initiating antibiotic therapy, as antibiotics may contaminate the
sample and prevent identification of the infectious organism (Option 4).
(Options 1 and 2) Administering medications for comfort, completion of
documentation, and facility-based report protocols should be done as soon as possible.
However, to prevent progression to sepsis, treatment of a suspected CRBSI should not
be delayed.
(Option 3) Initiation of antibiotics is essential in treating infection and preventing its
progression. However, the nurse should first draw blood cultures and remove the CVC,
if possible.
Educational objective:
When caring for a client with signs of a central line–related bloodstream infection, the
nurse should obtain blood cultures and remove the device, if possible, before beginning
antibiotic therapy. Other nursing interventions (eg, symptom management,
documentation) should be done after initiating treatment of the infection.
Additional Information
,Pharmacological and Parenteral Therapies
NCSBN Client Need
After listening to the parents' reports and seeing the following pediatric clients, the nurse knows
that which client demonstrates signs of abuse that may necessitate mandatory reporting?
1- year-old with dyspnea, drooling, and a swollen tongue after eating part of a
1. houseplant [2%]
2- year-old who is crying and has a large forehead hematoma after falling out of a chair [5%]
2.
3- year-old with second-degree burns on the face after pulling a cup of hot tea off the
3. table [3%]
5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures after falling
from a tree [87%]
4.
,The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with
state or provincial mandatory reporting. Signs of abuse may include:
• Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures)
• Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from
immersion in scalding liquid
• Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4)
• Injuries to genitalia
• Lapsed time between the injury and the time when care is sought
• Inconsistency between the injury and the caregiver's explanation of the injury (eg,
client's developmental age, mechanism of injury)
(Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg,
aspiration or poisoning from foreign objects in the mouth, climbs onto and falls from furniture,
pulling of objects from the table). The injuries and caregivers' explanations are reasonable for
these clients. Prior to discharge, the nurse should instruct caregivers on child safety measures
within the home to prevent future injury.
Educational objective:
The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated
injuries in varied stages of healing, shaken baby syndrome, and injuries to genitalia. Suspicion
of abuse necessitates mandatory reporting according to state or provincial laws.
Additional Information
Psychosocial Integrity
NCSBN Client Need
The nurse caring for a male client prepares to insert an indwelling urinary catheter. The
nurse assesses for allergies, explains the procedure to the client, and asks unlicensed
assistive personnel to perform perineal care while equipment is gathered. Place in
order the steps the nurse should take when inserting the urinary catheter. All options
must be used.
, Steps for indwelling urinary catheter insertion for the male client include:
• Perform hand hygiene and open sterile catheterization kit (Option 3).
• Apply sterile gloves and place sterile fenestrated drape with opening
centered over penis (Option 2).
• Maintaining sterility of gloves, arrange remaining kit supplies on sterile field.
Remove protective covering from catheter, lubricate catheter tip, and pour
antiseptic solution over cotton balls or swab sticks.
• Firmly grasp penis with nondominant hand, retracting foreskin if present.
Nondominant hand is now considered contaminated and remains in this position
for duration of procedure (Option 6).
• Use dominant (sterile) hand to cleanse in a circular motion from the meatus to
the glans with antiseptic solution using cotton balls or swab sticks. Use new
cotton ball/swab stick with each swipe (Option 4).
• Use dominant hand to pick up catheter and insert it until urine return is
visualized in catheter tubing (Option 5).
• Advance to bifurcation of catheter tubing. Hold in place and inflate balloon
(Option 1). Urine return in catheter tubing may be from urethra and does not
indicate that balloon tip is fully inside bladder. Because male urethra varies in
length, balloon should not be inflated until catheter is fully advanced.
Educational objective:
To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply
nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that
the client has a temperature of 102 F (38.8 C). Which new prescription from the health care
provider should the nurse implement first?
Administer ondansetron 4 mg IV push PRN for nausea or vomiting [3%]
1.
Document the occurrence and notify the hospital's epidemiology team [1%]
2.
Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV [13%]
3.
Obtain blood cultures and discontinue the central venous catheter [81%]
4.
Central venous catheters (CVCs) are used in the treatment of clients who require
long-term IV access or are prescribed hypertonic solutions (eg, total parenteral nutrition)
or vesicant medications. CVCs can serve as a portal of entry for bacteria, which
increases the risk of developing serious bloodstream infections. Nurses caring for
clients with CVCs should report any new or worsening signs of infection (eg, fever,
chills, erythema at the CVC site) to the health care provider because central line–related
bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis.
In response to a possible CRBSI, the CVC should be removed as soon as possible to
prevent continued exposure to the infection source. Blood cultures should be
obtained before initiating antibiotic therapy, as antibiotics may contaminate the
sample and prevent identification of the infectious organism (Option 4).
(Options 1 and 2) Administering medications for comfort, completion of
documentation, and facility-based report protocols should be done as soon as possible.
However, to prevent progression to sepsis, treatment of a suspected CRBSI should not
be delayed.
(Option 3) Initiation of antibiotics is essential in treating infection and preventing its
progression. However, the nurse should first draw blood cultures and remove the CVC,
if possible.
Educational objective:
When caring for a client with signs of a central line–related bloodstream infection, the
nurse should obtain blood cultures and remove the device, if possible, before beginning
antibiotic therapy. Other nursing interventions (eg, symptom management,
documentation) should be done after initiating treatment of the infection.
Additional Information
,Pharmacological and Parenteral Therapies
NCSBN Client Need
After listening to the parents' reports and seeing the following pediatric clients, the nurse knows
that which client demonstrates signs of abuse that may necessitate mandatory reporting?
1- year-old with dyspnea, drooling, and a swollen tongue after eating part of a
1. houseplant [2%]
2- year-old who is crying and has a large forehead hematoma after falling out of a chair [5%]
2.
3- year-old with second-degree burns on the face after pulling a cup of hot tea off the
3. table [3%]
5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures after falling
from a tree [87%]
4.
,The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with
state or provincial mandatory reporting. Signs of abuse may include:
• Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures)
• Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from
immersion in scalding liquid
• Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4)
• Injuries to genitalia
• Lapsed time between the injury and the time when care is sought
• Inconsistency between the injury and the caregiver's explanation of the injury (eg,
client's developmental age, mechanism of injury)
(Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg,
aspiration or poisoning from foreign objects in the mouth, climbs onto and falls from furniture,
pulling of objects from the table). The injuries and caregivers' explanations are reasonable for
these clients. Prior to discharge, the nurse should instruct caregivers on child safety measures
within the home to prevent future injury.
Educational objective:
The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated
injuries in varied stages of healing, shaken baby syndrome, and injuries to genitalia. Suspicion
of abuse necessitates mandatory reporting according to state or provincial laws.
Additional Information
Psychosocial Integrity
NCSBN Client Need
The nurse caring for a male client prepares to insert an indwelling urinary catheter. The
nurse assesses for allergies, explains the procedure to the client, and asks unlicensed
assistive personnel to perform perineal care while equipment is gathered. Place in
order the steps the nurse should take when inserting the urinary catheter. All options
must be used.
, Steps for indwelling urinary catheter insertion for the male client include:
• Perform hand hygiene and open sterile catheterization kit (Option 3).
• Apply sterile gloves and place sterile fenestrated drape with opening
centered over penis (Option 2).
• Maintaining sterility of gloves, arrange remaining kit supplies on sterile field.
Remove protective covering from catheter, lubricate catheter tip, and pour
antiseptic solution over cotton balls or swab sticks.
• Firmly grasp penis with nondominant hand, retracting foreskin if present.
Nondominant hand is now considered contaminated and remains in this position
for duration of procedure (Option 6).
• Use dominant (sterile) hand to cleanse in a circular motion from the meatus to
the glans with antiseptic solution using cotton balls or swab sticks. Use new
cotton ball/swab stick with each swipe (Option 4).
• Use dominant hand to pick up catheter and insert it until urine return is
visualized in catheter tubing (Option 5).
• Advance to bifurcation of catheter tubing. Hold in place and inflate balloon
(Option 1). Urine return in catheter tubing may be from urethra and does not
indicate that balloon tip is fully inside bladder. Because male urethra varies in
length, balloon should not be inflated until catheter is fully advanced.
Educational objective:
To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply
