A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy.

Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

Choice A reason:

Arching should not be expected. Arching of the body is not a typical manifestation of bacterial pneumonia. It may be seen in infants with certain conditions such as abdominal pain or neurologic issues, but it is not specific to pneumonia.

Choice B reason:

Drooling should not be expected. Drooling is not a common manifestation of bacterial pneumonia. It may be seen in certain conditions affecting the throat or mouth, but it is not directly related to pneumonia.

Choice C reason:

Fever is the correct answer. Bacterial pneumonia is an infection in the lungs caused by bacteria. When a child has bacterial pneumonia, their body's immune system responds to the infection, leading to inflammation and fever.

Choice D reason:

Steatorrhea should not be expected. Steatorrhea refers to fatty, bulky, and foul-smelling stools and is not associated with bacterial pneumonia. Steatorrhea may be seen in conditions affecting the gastrointestinal system and fat absorption.

Choice E reason:

Tinnitus should not be expected. Tinnitus is the perception of noise or ringing in the ears and is not a typical manifestation of bacterial pneumonia. Tinnitus can be associated with various ear-related conditions or medication side effects, but it is not directly related to pneumonia.

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.