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 B

Explanation

A. Restraints should be secure but not too tight to prevent injury or impaired circulation.
B. Ensuring the knot can be quickly released is critical for the client's safety in case of emergency.
C. A double turn or square knot would make the restraint difficult to remove quickly, posing a safety risk.
D. Restraints should never be tied to side rails as this can cause injury if the rails are moved.

A. Discourage visits from the client's friends. B. Provide a daily session with a play therapist. C. Vary the child's schedule each day. D. Encourage the client to complete school work.

Correct Answer is D

Explanation

A. Discouraging visits from friends may contribute to social isolation, which can negatively impact the child's psychosocial well-being. Encouraging social interactions, when appropriate, is generally beneficial.
B. While play therapy may be useful in certain situations, it may not be the primary focus for a 10-year-old child. Encouraging age-appropriate activities and interactions, including school work, is important.
C. Varying the child's schedule each day might introduce unnecessary stress and disrupt the sense of routine and stability, which is essential for psychosocial well-being.
D. Encouraging the client to complete school work is aligned with Erikson's psychosocial stage of industry vs. inferiority. This stage emphasizes the importance of developing competence and skills, including academic achievements, during the school-age years. Supporting the child's educational needs is crucial for positive psychosocial development.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Correct Answer is B

Explanation

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

Correct Answer is D

Explanation

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

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