The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take?

Respond to the code.

Call for an assistant

Finish the procedure.

Close the room door.

Answer and Explanation

The Correct Answer is A

A.   A code blue indicates a life-threatening emergency. The nurse's primary responsibility is to attend to the collapsing client immediately. The PICC removal can be completed later.

B.   Calling for an assistant allows the nurse to ensure the PICC removal is completed safely while also responding to the emergency situation.
C.   Finishing the procedure would delay the response to the code, potentially compromising the care of the client experiencing the emergency.
D.   Closing the room door is not relevant to managing either situation safely.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A. Given the client's chronic kidney disease and the risk of fluid overload, a high rate of normal saline infusion may not be appropriate without careful assessment and specific indication from the healthcare provider.
B. Monitoring daily weight is essential in managing fluid balance and assessing for potential fluid overload, especially in a child with chronic kidney disease.

C. Accurate measurement of intake and output is crucial in managing fluid balance and monitoring kidney function, particularly in a patient with a history of acute kidney injury and chronic kidney disease.
D. The client already has an elevated potassium level, and administering a potassium-sparing diuretic could worsen hyperkalemia, leading to dangerous cardiac complications.
E. Continuous monitoring of oxygen saturation is important due to the presence of bibasilar infiltrates on the chest X-ray, which could indicate a potential respiratory issue.
F. ECG monitoring is indicated due to the elevated potassium level (5.3 mEq/L), which can cause cardiac arrhythmias. The irregular heart rate further supports the need for ECG monitoring.

A. Bring a sterile chest drainage unit from central supply to the unit. B. Call the pharmacy to obtain a client's next antibiotic dose. C. Observe a client's gait to determine the need for assistance. D. Evaluate a client's urinary catheter for proper drainage.

Correct Answer is A

Explanation

A. Bringing a sterile chest drainage unit from central supply is a task that does not require clinical judgment and is suitable for a UAP.
B. Calling the pharmacy involves understanding and communication about medications, which should be handled by licensed staff.
C. Observing a client's gait to determine the need for assistance involves assessment and clinical judgment, which is beyond the UAP's scope.

D. Evaluating a client's urinary catheter for proper drainage requires assessment skills that are within the scope of licensed nurses.

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The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

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