A nurse is caring for a client who has a peripherally inserted central catheter (PICC) for the administration of total parenteral nutrition (TPN). The transparent dressing over the insertion site requires replacement. Which of the following actions should the nurse take?

Aspirate the catheter to check for a brisk blood return.

Use sterile technique for the procedure.

Cleanse the insertion site with hydrogen peroxide.

Flush the TPN port with 20 mL of 0.9% sodium chloride.

Answer and Explanation

The Correct Answer is B

Choice A reason: Aspirating the catheter to check for a brisk blood return is not typically recommended as a routine action when replacing the dressing of a PICC line used for TPN. This action is performed to verify patency and placement of the catheter, but it is not directly related to the dressing change procedure.

Choice B reason: Using sterile technique for the procedure is essential when replacing the dressing of a PICC line. Maintaining sterility is crucial to prevent infection, as the PICC line provides direct access to the central venous system. The nurse should use sterile gloves and follow aseptic protocols to minimize the risk of introducing pathogens at the catheter insertion site.

Choice C reason: Cleansing the insertion site with hydrogen peroxide is not recommended for PICC line care. Hydrogen peroxide can be damaging to the tissue and may delay healing. Instead, a chlorhexidine-based antiseptic is typically used to clean the skin around the insertion site during dressing changes to reduce microbial flora and prevent infection.

Choice D reason: Flushing the TPN port with 20 mL of 0.9% sodium chloride is a practice used to maintain catheter patency, but it is not part of the dressing change procedure. Flushing is usually done before and after administering medication or nutrition, not specifically during a dressing change.

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Correct Answer is C

Explanation

Choice A reason: While bladder control issues can significantly affect a client's quality of life, they are typically managed by a urologist or a specialist in continence, rather than an occupational therapist. Occupational therapy focuses on improving the ability to perform activities of daily living (ADLs), which generally does not include bladder control.

Choice B reason: Difficulty swallowing, known as dysphagia, can be a symptom of myasthenia gravis due to muscle weakness. Although it is a serious concern, it is usually managed with the help of a speech therapist who specializes in swallowing difficulties, rather than an occupational therapist.

Choice C reason: Having a hard time with brushing hair is directly related to the performance of ADLs, which is the primary focus of occupational therapy. An occupational therapist can assist the client by teaching energy conservation techniques, providing adaptive equipment, and modifying the task to make it easier for the client to maintain personal grooming independently.

Choice D reason: Preferring a wheelchair over a walker is a matter of mobility and personal preference. While occupational therapy can help with mobility issues, this statement alone does not indicate a need for occupational therapy unless the client has difficulty performing ADLs due to the choice of mobility aid.

A. Droplet precautions B. Standard precautions C. Airborne precautions D. Contact precautions

Correct Answer is B

Explanation

Choice A reason: Droplet precautions are used for diseases that are transmitted through large respiratory droplets produced by coughing, sneezing, or talking. AIDS, caused by the Human Immunodeficiency Virus (HIV), is not transmitted through respiratory droplets, so droplet precautions are not necessary for a client with AIDS.

Choice B reason: Standard precautions are the primary strategy for the prevention of infection transmission and apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. These precautions include hand hygiene, the use of personal protective equipment (PPE) like gloves and gowns, and safe injection practices. Since HIV/AIDS can be transmitted through blood and certain body fluids, standard precautions are essential when caring for clients with AIDS.

Choice C reason: Airborne precautions are used for diseases that are transmitted by small droplet nuclei that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance. HIV/AIDS is not transmitted through the airborne route, so airborne precautions are not indicated for clients with AIDS.

Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or indirect contact with surfaces or patient care items. While HIV can be present in body fluids, it is not easily transmitted through casual contact. Therefore, contact precautions are not specifically required for clients with AIDS unless they have other conditions that warrant such precautions.

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A nurse is caring for a client who has a peripherally inserted central catheter (PICC) for the administration of total parenteral nutrition (TPN). The transparent dressing over the insertion site requires replacement. Which of the following actions should the nurse take?

Nursing Test Bank

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