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
This is because coarctation of the aorta is a congenital condition where the aorta is narrow, usually in the area where the ductus arteriosus inserts. This causes a decrease in blood flow to the lower body, resulting in weak or absent pulses in the femoral arteries.
The other choices are incorrect for the following reasons:
- Choice A, frequent nosebleeds, is not a typical sign of coarctation of the aorta.
Nosebleeds can be caused by many factors, such as dry air, allergies, trauma, or bleeding disorders.
- Choice B, upper extremity hypotension, is also not a common finding in coarctation of the aorta. In fact, patients with this condition may have high blood pressure in the upper extremities due to the increased resistance of the narrowed aorta.
- Choice D, increased intracranial pressure, is not directly related to coarctation of the aorta.
Increased intracranial pressure can be caused by various conditions that affect the brain, such as head injury, stroke, infection, or tumor.
Normal ranges for blood pressure and pulse vary depending on age, sex, and health status.
However, some general guidelines are:
- Blood pressure: less than 120/80 mmHg for adults; less than 95/65 mmHg for infants.
- Pulse: 60 to 100 beats per minute for adults; 100 to 160 beats per minute for infants.
Correct Answer is D
Explanation
The correct answer is choice D. This test should be performed after your baby is 24 hours old. This is because newborn genetic screening is a set of laboratory tests that detect a set of known genetic diseases that can affect a child’s long-term health or survival. The test is performed on a blood sample obtained from a heel prick when the baby is two or three days old. Performing the test after 24 hours ensures that the baby has had enough time to metabolize certain substances that could interfere with the accuracy of the test.
Choice A is wrong because the blood sample is not drawn from the baby’s inner elbow, but from the heel. Choice B is wrong because the baby does not need to drink water prior to the test, as this could dilute the blood sample and affect the results. Choice C is wrong because the test does not need to be repeated when the baby is 2 months old, unless there is a positive or inconclusive result from the first test.
Newborn genetic screening is important for early detection and intervention of certain conditions that can cause serious health problems or disability if left untreated. Parents should be informed about the benefits and limitations of the test, as well as their rights and options regarding consent and confidentiality.
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