A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care?
Measure the arm circumference above the insertion site daily.
Administer sedation
Schedule an MRI post procedure to verify placement
Use gauze to secure an arm board to the involved extremity
The Correct Answer is A
Choice A reason:
Measuring the arm circumference above the insertion site daily is appropriate. When planning care for a client scheduled to receive a peripherally inserted central catheter (PICC) in the arm, it is appropriate for the nurse to include measuring the arm circumference above the insertion site daily. This intervention is essential to monitor for any signs of complications, such as edema or swelling, which could indicate thrombosis or infiltration at the insertion site.
Choice B reason:
Administering sedation Administering sedation is not a routine intervention for a PICC insertion procedure is inappropriate. Sedation might be considered for certain procedures, but it is not typically used for PICC insertions. PICC insertions are generally performed with local anaesthesia at the insertion site.
Choice C reason:
Scheduling an MRI post procedure to verify placement An MRI is not typically used to verify the placement of a PICC. The placement of a PICC is usually confirmed using X-ray or other imaging methods that can visualize the catheter's location within the central veins. Post-procedure verification of PICC placement is essential to ensure proper positioning and to prevent complications.
Choice D reason:
Using gauze to secure an arm board to the involved extremity Using gauze to secure an arm board to the involved extremity is not a common practice for securing a PICC. After a PICC insertion, a securement device specifically designed for PICCs is typically used to secure the catheter in place and prevent movement.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D) Scrambled eggs and toast with milk.
For a client who follows kosher dietary traditions, it's essential to adhere to the rules and restrictions that pertain to kosher food preparation and consumption. Among the given options, the only one that aligns with kosher dietary guidelines is scrambled eggs and toast with milk.
The other options (A, B, and C) contain non-kosher ingredients, such as ham, shrimp, and bacon, which are not considered kosher. Additionally, mixing meat and dairy products is generally not allowed in kosher dietary practices. So, options A, B, and C would not be appropriate for someone following kosher dietary traditions.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
safety followed by the client’s pain.
The nurse should first address the client’s safety because it is the most basic and essential need according to Maslow’s hierarchy of needs. The client may be at risk of abuse or neglect from his adult child, as evidenced by the bruises, body odor, unclean clothes, low BMI, and submissive behavior. The nurse should assess the client for signs of physical or emotional abuse and report any suspicions to the appropriate authorities. The nurse should also provide a safe and supportive environment for the client and encourage him to express his feelings and concerns.
The nurse should then address the client’s pain because it is a physiological need that affects the client’s comfort and well-being. The client rates his pain as 8 on a 0 to 10 scale and is not moving his right arm. The nurse should assess the client’s arm for signs of injury, such as swelling, deformity, or bleeding. The nurse should also administer analgesics as prescribed and monitor the client’s response to pain relief. The nurse should also provide non-pharmacological interventions, such as ice packs, elevation, or distraction.
The other choices are less urgent than safety and pain. The client’s abrasions are superficial and do not pose a significant risk of infection or bleeding. The client’s hygiene is important but not a priority at this time. The client’s BMI indicates that he is underweight, but this is a chronic condition that requires long-term nutritional intervention. The client’s heart rate is slightly elevated but not alarming, and may be due to pain, anxiety, or dehydration.
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