3 UWorld NCLEX-PN

3 UWorld NCLEX-PN
1. The nurse is preparing
to change a central venous catheter dressing
using a chlorhexidine
gluconate (CHG)-impregnated patch and
transparent adhesive
dressing. Place the
procedural steps in the
correct order. All options must be used.
1. Apply CHG patch
over catheter insertion
cite and cover with
a sterile transparent
dressing
2. Cleanse the site with
CHG for at least 30
seconds using friction;
allow to air-dry completely
3. Discard the clean
gloves perform hand
hygiene, and apply
sterile gloves
4. Perform hand hygiene, don face mask,
place a mask on the
client, and apply clean
gloves
5. Remove old dressing and CHG-impregnated patch; inspect insertion site
CORRECT ANSWER: 4, 5, 3, 2, 1
Central line dressing changes are sterile procedures and must be performed correctly to prevent
infection. Steps should be performed in the following
order:
• Perform meticulous hand hygiene.
• Don a surgical mask and apply a mask to the client
(or ask the client to turn the head away from the
dressing). Apply clean gloves (Option 4).
• Remove the old dressing, including the chlorhexidine gluconate (CHG) - impregnated patch, making
sure not to touch the insertion site (Option 5).
• Inspect the site for drainage, erythema, heat, or
inflammation.
• Discard the clean gloves, perform hand hygiene,
and apply sterile gloves (Option 3).
• Cleanse the site with antimicrobial solution (eg,
CHG), in a back-and-forth motion using friction, for
at least 30 seconds; allow to air-dry completely (Option 2).
• Apply the CHG-impregnated patch over the
catheter insertion site and cover with the sterile
transparent dressing (or use a CHG gel transparent
dressing), making certain the edges of the dressing
adhere well (Option 1).
• Sign, date, and initial the dressing.
• Document the procedure.