An unlicensed assistive personnel (UAP) is assisting with the care of a client with a peripherally inserted central venous catheter (PICC). Which guidance should the practical nurse (PN) provide to the UAP?
Be sure to keep the head of the client's bed elevated.
Change the dressing over the catheter insertion site.
Feed the client all meals to reduce arm movement.
Use the opposite arm for blood pressure measurement.
The Correct Answer is D
A. Keeping the head of the bed elevated is not specifically related to the care of a PICC line. The elevation may be a general comfort measure but is not a specific instruction for PICC line management.
B. Changing the dressing over the PICC line insertion site is a sterile procedure that should be performed by a licensed nurse, not a UAP. This task requires specific training and adherence to infection control practices.
C. Feeding the client all meals to reduce arm movement is not necessary and may be overly restrictive. The UAP’s role does not include limiting the client's activity beyond reasonable measures.
D. Using the opposite arm for blood pressure measurement is the correct guidance. It prevents potential interference with the PICC line and helps avoid complications such as dislodgement or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity.
B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin.
C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor.
D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.
Correct Answer is D
Explanation
A. Urinary output of 50 mL/hour is within normal limits and does not directly impact morning care instructions.
B. An oxygen saturation measurement of 95 to 96% is generally acceptable and does not necessitate specific morning care instructions.
C. A blood pressure of 144/84 mm Hg is elevated but not critical in the context of morning care instructions for the UAP.
D. Orientation to person only indicates a cognitive impairment that could affect the client’s ability to understand or follow instructions, cooperate during care, and ensure safety during activities like bathing or moving. This is the most critical factor to consider when providing instructions to the UAP.
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