A nurse is evaluating patients who have been prescribed intravenous therapy. Which observation for a patient with a Peripherally Inserted Central Catheter (PICC) demands immediate attention?

The PICC was inserted 4 weeks ago.

The initial site dressing is 3 days old.

A securement device is missing.

Swelling is observed in the upper extremity.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
While PICCs are typically intended for shorter-term use (up to 12 weeks), the fact that a PICC has been in place for 4 weeks is not, in itself, an immediate cause for concern. Regular assessment of the catheter and site is crucial, but the duration of placement alone does not warrant immediate attention.
Choice B rationale:
While it's generally recommended to change PICC dressings every 7 days, a dressing that is 3 days old is not an immediate emergency. The nurse should prioritize changing the dressing as soon as possible, but it does not require the same level of urgency as other potential complications.
Choice C rationale:
A missing securement device is a concern because it can increase the risk of catheter dislodgement or migration. However, it does not necessarily indicate an immediate threat to the patient's well-being. The nurse should promptly address the missing securement device, but it would not be the most pressing issue compared to swelling in the extremity.
Choice D rationale:
Swelling in the upper extremity where the PICC is located is a significant finding that demands immediate attention. It can be a sign of several serious complications, including:
Thrombosis: A blood clot within the vein, which can obstruct blood flow and lead to pain, swelling, and potentially more severe consequences like deep vein thrombosis (DVT) or pulmonary embolism (PE).
Infection: Inflammation and infection at the insertion site or within the bloodstream, which can cause swelling, redness, warmth, and pain. If left untreated, infection can progress to sepsis, a life-threatening condition.
Phlebitis: Inflammation of the vein, which can cause pain, redness, and swelling along the vein.
Infiltration: Leakage of fluids or medications into the surrounding tissue, leading to swelling and discomfort.
Prompt action is crucial in these cases to prevent further complications and ensure patient safety. The nurse should immediately notify the appropriate healthcare provider, initiate necessary interventions, and closely monitor the patient's condition.

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Correct Answer is D

Explanation

Choice A rationale:
It is not accurate to state that the patient is at risk for seizures due to fungal infections. While fungal infections can occur in individuals with HIV-1, they are not a primary cause of seizures in this population.
Linking fungal infections directly to seizure risk without clear evidence could cause unnecessary anxiety in the patient. It's important to provide accurate and relevant information to patients.
Choice B rationale:
Responding with "I have no idea why you would be taking this drug" is unprofessional and unhelpful.
Nurses are expected to have a basic understanding of the medications their patients are taking and to be able to provide education and support.
It's essential to demonstrate knowledge and confidence when interacting with patients.
Choice C rationale:
While gabapentin can have mood-elevating effects in some individuals, it is not primarily used as an antidepressant. Mentioning this potential side effect without clarifying the primary purpose of the medication could mislead the patient. It's crucial to prioritize the main indication for the medication to avoid confusion.
Choice D rationale:
This is the most appropriate response because it accurately explains the primary reason for prescribing gabapentin to this patient.
Gabapentin is commonly used to treat neuropathic pain, which is pain caused by nerve damage.
HIV-1 can often lead to neuropathic pain, making gabapentin a valuable treatment option in this population.
Providing clear and accurate information about medication purpose builds trust and understanding between the nurse and the patient.

A. This medication may cause hair loss. B. This medication may cause a burst of energy. C. This medication should be taken on an empty stomach. D. The most serious adverse effect of this medication is retinal damage.

Correct Answer is D

Explanation

Rationale for Choice A:

Hydroxychloroquine does not typically cause hair loss as a significant side effect. While some anecdotal reports have suggested hair thinning as a possibility, it's not a well-established or common occurrence in clinical studies.

If a patient experiences hair loss while on hydroxychloroquine, it's essential to rule out other potential causes, such as underlying medical conditions, stress, or nutritional deficiencies.

It's also important to note that some individuals may have a personal predisposition to hair loss, and medications can sometimes trigger or exacerbate this issue.

Rationale for Choice B:

Hydroxychloroquine is not known to cause a burst of energy. In fact, some patients may experience fatigue or drowsiness as a side effect.

It's crucial to inform patients about potential side effects to manage expectations and promote adherence to treatment.

If a patient experiences unexpected energy changes while taking hydroxychloroquine, it's essential to report this to their healthcare provider for further evaluation.

Rationale for Choice C:

Hydroxychloroquine is generally recommended to be taken with food or milk to reduce potential gastrointestinal side effects such as nausea and vomiting.

Taking it on an empty stomach could increase the risk of these side effects, which could impact medication adherence and effectiveness.

Rationale for Choice D:

Retinal damage is the most serious adverse effect of hydroxychloroquine. It can lead to irreversible vision loss if not detected and managed early.

Patients taking hydroxychloroquine must undergo regular eye examinations to monitor for any signs of retinal toxicity.

Early detection and prompt discontinuation of the medication can often prevent permanent vision loss.

It's crucial for nurses to educate patients about this potential risk and emphasize the importance of regular eye exams.

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A nurse is evaluating patients who have been prescribed intravenous therapy. Which observation for a patient with a Peripherally Inserted Central Catheter (PICC) demands immediate attention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with HIV-1 is curious as to why gabapentin is included in their medication regimen, despite not having a history of seizures. What would be the most appropriate response from the nurse?

Correct Answer is D

Explanation

The primary healthcare provider prescribes Hydroxychloroquine for a patient. What information should the nurse include when discussing this medication with the patient?

Correct Answer is D

Explanation

Rationale for Choice A:

Rationale for Choice B:

Rationale for Choice C:

Rationale for Choice D:

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