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 D

Explanation

Choice A reason: Taking two tablets PO every 15 minutes is not the standard protocol for nitroglycerin administration for chest pain. This method could lead to an overdose and significant hypotension (low blood pressure), which can be dangerous.

Choice B reason: One tablet SL every 15 minutes, up to 5 times, is also not the standard protocol. While sublingual administration is correct, the frequency and the total number of doses are higher than recommended, which could result in adverse effects such as headache, dizziness, or a severe drop in blood pressure.

Choice C reason: One tablet PO every one hour, up to 5 times, is not a recommended method for acute chest pain relief from angina. Oral administration does not provide the rapid onset of action required for acute angina relief.

Choice D reason: One tablet SL every 5 minutes, up to 3 times, is the correct protocol for nitroglycerin administration when experiencing chest pain due to angina. If pain persists after the first dose, the patient can take a second dose after 5 minutes, and if needed, a third dose after another 5 minutes. If chest pain continues after three doses in 15 minutes, emergency medical help should be sought immediately.

A. A DNR prescription means you will only receive pain medication for your treatments. B. A DNR prescription will limit your current treatment regimen. C. A DNR prescription will allow you to continue with your current treatment regimen. D. A DNR prescription will limit your ability to receive invasive procedures.

Correct Answer is C

Explanation

Choice A reason: The statement that a DNR prescription means the client will only receive pain medication is incorrect. A DNR (Do Not Resuscitate) order does not affect the provision of treatments other than those required to resuscitate the patient if their heart stops or they stop breathing. Patients with a DNR can still receive all other medical treatments and interventions aimed at managing symptoms and improving quality of life, including pain management.

Choice B reason: A DNR prescription does not limit the current treatment regimen in terms of ongoing treatments for the patient's condition. The DNR order specifically refers to not performing CPR (cardiopulmonary resuscitation) if the patient's breathing or heart stops. All other aspects of the patient's care plan, including aggressive treatments, can continue if they align with the patient's wishes and medical advice.

Choice C reason: This is the correct statement. A DNR prescription allows the patient to continue with their current treatment regimen. It is a directive that applies only in the event of cardiac or respiratory arrest, indicating that CPR should not be performed. However, it does not preclude the patient from receiving other medical treatments or interventions.

Choice D reason: A DNR prescription does not inherently limit the ability to receive invasive procedures. The decision to pursue or avoid invasive procedures would be based on the patient's overall treatment goals, prognosis, and personal preferences, not solely on the presence of a DNR order.

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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

Naxlex Comprehensive Predictor Exams

The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain:

Correct Answer is D

Explanation

A client who has a terminal illness asks the nurse, "If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?" Which of the following statements should the nurse provide to explain a DNR prescription?

Correct Answer is C

Explanation

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