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 C
Explanation
The correct answer is choice C, malaise.
Malaise is a general feeling of discomfort, weakness, or illness that can be a sign of infection. According to the health search result from Focus Medica , bacterial pneumonia is an infection of the air sacs in one or both lungs that causes symptoms such as cough with phlegm, fever, chills, and difficulty breathing.
Malaise is one of the symptoms that may follow these signs of infection.
Choice A, drooling, is wrong because it is not a typical symptom of bacterial pneumonia.
Drooling can be caused by other conditions, such as sore throat, dental problems, or neurological disorders.
Choice B, tinnitus, is wrong because it is not a symptom of bacterial pneumonia either.
Tinnitus is a ringing or buzzing sound in the ears that can be caused by exposure to loud noise, ear infections, or other ear problems.
Choice D, rhinorrhea, is wrong because it is not specific to bacterial pneumonia.
Rhinorrhea is a runny nose that can be caused by many factors, such as allergies, colds, or sinus infections.
Rhinorrhea can sometimes occur with viral pneumonia, but not usually with bacterial pneumonia.
Correct Answer is A
Explanation
The correct answer is choice A. Limit oral feedings to 30 min in length.
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in the prone position can compromise the respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
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