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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F","H"]
Explanation
A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.
G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.
Correct Answer is B
Explanation
A. The UAP should not make medication decisions; only a nurse or healthcare provider should do this after assessment.
B. The nurse should evaluate the client’s heart rhythm to determine the effectiveness of the amiodarone and to assess for any arrhythmias or side effects of the medication.
C. Checking the regularity of peripheral pulses is important but secondary to assessing the heart rhythm directly.
D. Restarting the IV infusion might be necessary if there are issues with the IV site, but the primary concern is the client's cardiac status.
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