The nurse is preparing to administer a liter of fluid through a client's central line. What should the nurse do after attaching the syringe to the designated port?
1. Ask the client to cough
2. Aspirate for a blood return
3. Withdraw 20 mL of blood
4. Inject 10 mL of saline flush
2
Rationale 1: The client should not cough while the access port is being used.
Rationale 2: After attaching the syringe, aspirate for blood return, using very little force, to check for lumen patency and placement.
Rationale 3: The nurse is not drawing a blood sample.
Rationale 4: Saline flush occurs after the blood return is assessed.
Global Rationale: After attaching the syringe, aspirate for blood return, using very little force, to check for lumen patency and placement. After attaching the syringe, aspirate for blood return, using very little force, to check for lumen patency and placement. : The nurse is not drawing a blood sample. Saline flush occurs after the blood return is assessed.
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a. check for CVA tenderness or flank pain b. obtain a urine sample to check for proteinuria c. assess for additional signs of fluids overload d. alert the HCP about the respiratory symptoms