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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:

Completing an incident report is not the correct action. An incident report should be completed as part of the hospital's protocol to document the medication error and ensure appropriate follow-up and investigation.

Choice B reason:

Checking the client for indications of bleeding is the correct action to be taken. In this situation, the nurse's first priority should be to assess the client for indications of bleeding, as the client received a significantly higher dose of IV heparin than prescribed. Heparin is an anticoagulant medication used to prevent blood clots, and an overdose can increase the risk of bleeding.

After administering the wrong dose of medication, the nurse's immediate concern is the client's safety and well-being. Checking for signs of bleeding, such as petechiae, ecchymosis, hematomas, bleeding gums, melena (black, tarry stools), haematuria (blood in urine), or any other unusual bleeding, is crucial.

Choice C reason:

Monitor the client's aPTT levels: This is not the correct action to be taken. Monitoring the client's activated partial thromboplastin time (aPTT) levels is essential to assess the client's coagulation status and determine if the overdose of heparin has affected their clotting ability. The healthcare provider may adjust the heparin dosage based on the aPTT levels.

Choice D reason:

Notify the risk manager: This is not the correct action to be taken. The risk manager or appropriate supervisor should be informed about the medication error as soon as possible to initiate a thorough review of the incident and take necessary steps to prevent similar errors in the future.

A. Administer aspirin to the client B. Isolate the client from staff who are pregnant. C. Initiate airborne precautions. D. Monitor for the development of Koplik spots

Correct Answer is B

Explanation

The correct answer is choice B. Isolate the client from staff who are pregnant. Choice A rationale: Aspirin should not be administered to children or adolescents with viral infections like rubella due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage. Choice B rationale: Rubella (German measles) is particularly dangerous for pregnant women because it can cause congenital rubella syndrome in the fetus, leading to severe birth defects. Therefore, isolating the client from pregnant staff is crucial to prevent exposure. Choice C rationale: Airborne precautions are not necessary for rubella. Rubella is transmitted through respiratory droplets, so droplet precautions, not airborne precautions, are appropriate. Choice D rationale: Koplik spots are associated with measles (rubeola), not rubella. Therefore, monitoring for Koplik spots is not relevant for a client with rubella.

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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?

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