A nurse is obtaining a blood specimen from a client who has a peripherally inserted central catheter. Which of the following actions should the nurse take?
Use a 3 mL syringe to flush the catheter.
Cleanse the port with povidone-iodine prior to obtaining the specimen.
Flush with 20 mL of 0.9% sodium chloride after obtaining the blood sample.
Instruct the client to perform the Valsalva maneuver during the blood draw.
The Correct Answer is D
A. Use a 3 mL syringe to flush the catheter: Small syringes (3 mL) create high pressure that can damage the lumen of a peripherally inserted central catheter (PICC). Larger syringes, typically 10 mL or greater, are recommended to safely flush and maintain catheter integrity.
B. Cleanse the port with povidone-iodine prior to obtaining the specimen: Current guidelines recommend using an alcohol-based antiseptic (e.g., 70% isopropyl alcohol) rather than povidone-iodine for cleaning catheter hubs due to faster action and reduced contamination risk.
C. Flush with 20 mL of 0.9% sodium chloride after obtaining the blood sample: While flushing is required, the volume depends on the protocol and whether blood was drawn for lab testing. Immediate flushing with 10 mL is often sufficient; 20 mL may be excessive unless the protocol specifies.
D. Instruct the client to perform the Valsalva maneuver during the blood draw: Performing the Valsalva maneuver increases intrathoracic pressure and reduces the risk of air embolism when accessing a central line. This is a recommended safety measure during blood draws from PICC lines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The infant is swaddled but there is a blanket and a stuffed toy in the crib. Loose items increase the risk of suffocation and SUID, so this does not demonstrate safe sleep practices.
B. The infant is placed on their back, but there is a blanket and a stuffed toy in the crib. These items pose a suffocation risk and do not follow safe sleep guidelines.
C. The infant is placed on their back in a swaddle with no loose blankets or toys in the crib. This position aligns with American Academy of Pediatrics (AAP) recommendations for safe sleep to reduce the risk of SUID, demonstrating proper understanding of safe sleep practices.
Correct Answer is D
Explanation
A. Start another IV line in another extremity: Establishing a new IV line is necessary to continue therapy, but it is not the first action. Immediate steps must focus on preventing further tissue damage from the infiltrated vesicant.
B. Apply a warm, moist compress: Warm or cold compresses may be applied depending on the type of vesicant and institutional protocol, but this is a secondary intervention after stopping the infusion and protecting the tissue.
C. Disconnect IV tubing and aspirate medication from the IV catheter: Aspirating the remaining medication may help reduce tissue exposure, but it is performed after the infusion is stopped to prevent further infiltration.
D. Stop the infusion: Stopping the infusion immediately is the first and most critical action to prevent further tissue damage. Halting the delivery of the vesicant stops the source of injury and allows subsequent interventions to minimize local tissue necrosis.
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