TEST BANK FOR TAYLOR’S CLINICAL NURSING SKILLS A NURSING PROCESS APPROACH 5TH EDITION BY PAMELA B LYNN ALL CHAPTERS EXAM WITH ACTUAL QUESTIONS AND COMPLETE 100% CORRECT VERIFIED ANSWERS WITH RATIONALES WELL EXPLAINED BY EXPERTS AND GRADED A+ LATEST UPDATE

TEST BANK FOR TAYLOR’S CLINICAL NURSING SKILLS A NURSING PROCESS APPROACH 5TH EDITION BY PAMELA B LYNN ALL CHAPTERS EXAM WITH ACTUAL QUESTIONS AND COMPLETE 100% CORRECT VERIFIED ANSWERS WITH RATIONALES WELL EXPLAINED BY EXPERTS AND GRADED A+ LATEST UPDATE 2024 ALREADY PASSED!!!!!! WITH 100% GUARANTEED SUCCESS AFTER DOWNLOAD (ALL YOU NEED TO PASS YOUR EXAMS) embolism. When accessing the implanted port of a central venous access device (CVAD), what action should the nurse take to ensure the port is patent? Aspirate a few milliliters of blood into the extension tubing to check for blood return. Aspirate a few milliliters of blood into the syringe to check for blood return. Open the clamp on the extension tubing and instill 3 to 5 mL of air. Open the clamp on the extension tubing and flush with 3 to 5 mL of saline. Aspirate a few milliliters of blood into the extension tubing to check for blood return. Rational: The nurse should check the patency of the implanted port of the CVAD by pulling back on the syringe plunger to aspirate for blood return. Positive blood return indicates that the port is patent. The nurse should aspirate only a few milliliters of blood and should not allow blood to enter the syringe. Flushing the port with 3 to 5 mL of saline checks that the needle is placed correctly. Air should not be used to flush the port as this can cause air embolism. The nurse is flushing the implanted port of a client's central venous access device (CVAD) and meets resistance. What should the nurse do next? Ask the client to perform a Valsalva maneuver and place the client's arm below the heart. Change the position of the client and lower the head of the bed. Notify the health care provider immediately. Check that the clamp is open, gently push down on needle, and attempt to flush again. Check that the clamp is open, gently push down on needle, and attempt to flush again. Rational: The nurse should first check the clamp to ensure that it is open, and then gently push down on the needle and attempt to flush again. If this does not work, the nurse could ask the client to perform a Valsalva maneuver, change the position, or place the affected arm over the head. The nurse could also lower or raise the head of the bed. If the port still does not flush, the needle should be removed and a new needle inserted. If the port does not flush this time, the health care provider should be notified. The nurse is accessing the implanted port of a client's central venous access device (CVAD) to administer medications. After holding the port stable, the nurse should insert the needle into which location? right side of the port left side of the port top of the port center of the port center of the port Rationale: The nurse should visualize the center of the port and insert the needle through the skin into the port septum, located in the center of the port, until the needle hits the back of the port. To function properly, the needle must be in the middle of the port and inserted to the back wall of the port. A nurse is preparing to access the implanted port of a client's central venous access device (CVAD). The nurse asks the client to turn the head away from the access site, but the client is unable to do so. What is the next action by the nurse? Place a mask on the client. Urge the client not to cough. Ask the client to hold the breath. Tell the client to look away. Place a mask on the client. Rationale: Turning the head away from the access site helps to deter the spread of microorganisms. If a client is unable to turn the head away from the site, the nurse should place a mask on the client to help deter the spread of microorganisms. Masks may also be necessary based on facility policy. Asking the client to hold the breath, look away, or avoid coughing would not be effective in preventing the spread of microorganisms. The nurse is caring for a client who has an implanted port central venous access device (CVAD) and needs to have an intravenous (IV) solution infused. The nurse has appropriately prepared the solution,