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 D

Explanation

The correct answer is choice D. Administer analgesics on a scheduled basis for the first 24 hr.

This is because the child is at risk for developing peritonitis, which can cause severe abdominal pain.

Scheduled analgesics can provide better pain relief than PRN analgesics.

Choice A is wrong because the child should not be given anything by mouth until bowel sounds return, which can take up to 24 hr after surgery.

Giving clear liquids too soon can cause nausea, vomiting, and abdominal distension.

Choice B is wrong because cromolyn nebulized solution is used to prevent asthma attacks, not to treat appendicitis.

There is no indication that the child has asthma or needs this medication.

Choice C is wrong because applying a warm compress to the operative site can increase inflammation and infection risk.

A cold compress can be used to reduce swelling and pain, but only if prescribed by the provider.

A. Urine specific gravity B. Prealbumin C. Temperature D. Blood pressure

Correct Answer is B

Explanation

Choice A Reason:

Urine specific gravity: The specific gravity of 1.035 indicates concentrated urine and might be indicative of dehydration. However, the nurse should address this finding by encouraging increased fluid intake before reporting it to the provider.

Choice B Reason:

Prealbumin: The prealbumin level is 25 mg/dL. Prealbumin is a marker of nutritional status and can indicate the adequacy of protein intake and overall nutritional status. A level of 25 mg/dL is relatively low, which may suggest malnutrition or insufficient protein intake. This finding should be reported to the provider so that appropriate interventions can be initiated to address the client's nutritional needs.

Choice C Reason:

Temperature: The temperature is not mentioned in the provided information. If the temperature is within the normal range, there is no need to report it to the provider.

Choice D Reason:

Blood pressure: The blood pressure is not mentioned in the provided information. If the blood pressure is within the normal range, there is no need to report it to the provider.

It's important for the nurse to critically assess the client's medical record and prioritize the findings that require immediate attention or intervention. In this case, the low prealbumin level indicates a potential nutritional issue that needs to be addressed promptly. The nurse should communicate this finding to the healthcare provider to ensure appropriate management and care for the client.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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