To decrease the risk of infection associated with the introduction of bacteria from the TPN solution, the nurse will:
1. change the dressing every 3 days.
2. inspect the IV insertion site for redness.
3. assess temperature daily.
4. use a 0.22-micron inline filter.
Correct Answer: 4
Rationale 1: Changing the dressing will not decrease the bacterial content of the TPN solution.
Rationale 2: Redness at the IV site can indicate a local site infection.
Rationale 3: Assessing for a change in temperature can indicate infection, but it will not reduce the risk of infection.
Rationale 4: A 0.22-micron inline filter is used to reduce introduction of bacteria from the TPN solution.
Global Rationale: A 0.22-micron inline filter is used to reduce introduction of bacteria from the TPN solution. The other interventions are standard, but do not prevent introduction of bacteria from the fluid. They are site related or are useful for early identification of infection.
You might also like to view...
A patient has been prescribed rabeprazole (Aciphex). It will be important for the nurse to assess the patient's drug history to determine if the patient is taking which of the following drugs?
A) Levodopa B) Morphine C) Digoxin D) Dicyclomine hydrochloride
Which ingredient is often hidden in cough and cold syrups?
a. Potassium b. Alcohol c. Steroids d. Benzocaine
Nurses on the dialysis unit notice that changes in labeling of fluids have meant several alarming near misses in terms of wrong administration of fluids. They take this concern to the unit man-ager
As an advocate of nurse autonomy, the most appropriate response in this situation would be to: a. Ensure that the nurses are aware of the reasons for the change and how the deci-sion was made about the new labels. b. Discuss concerns about the labels and de-velop potential solutions that take into account changes that can be made at the local level and those that need system in-tervention. c. Suggest that the staff wait until they have become more familiar with the labels be-fore taking further action. d. Tell the staff that you will notify the pharmacy about these concerns and leave it up to the pharmacy to decide what should be done.
Which nursing intervention is most appropriate on the first day of alcohol detoxification?
A) Strongly encourage the client to attend two AA meetings. B) Educate the client about the biopsychosocial consequences of alcohol abuse. C) Monitor the client's vital signs every 4 hours, or more frequently if necessary. D) Ensure that the client consumes 95% of his or her meals.