A patient on the cardiac ﬂoor has just had a PlCC line placed by the MD. the Xray team has not verified the position of the catheter tip, yet. You check the heart monitor and notice she begins having an irregular heart rhythm called Atrial Fibrillation. You anticipate that the PlCC line is touching which chamber of the heart?

Left Ventricle

Right Ventricle

Right Atria

Left Atria

Answer and Explanation

The Correct Answer is C

A PICC line is a long, thin tube that’s inserted through a vein in your arm and passed through to the larger veins near your heart 1. If the PICC line is touching a chamber of the heart, it is most likely touching the right atrium 2.

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Correct Answer is C

Explanation

A. Perform respiratory assessment. B. Document hypoxemia. C. Check the placement of the pulse oximeter. D. Report pulse oximetry to the health care provider.

Correct Answer is A

Explanation

Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.

Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.

While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

Correct Answer is A

Explanation

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