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
Explanation
A. Clients with Addison's disease need to understand situations that require an adjustment in their steroid dose, such as stress, infection, or surgery, to prevent an Addisonian crisis.
B. Daily temperature checks are not typically required for Addison's disease unless there is a concern for infection.
C. While daily weights can be helpful in some conditions, it is not the primary focus for managing Addison's disease.
D. Dietary modifications such as high fiber, low fat may be beneficial for overall health but are not specific to managing Addison's disease.
Correct Answer is ["A","B","E"]
Explanation
A. This intervention is likely to be ordered due to the patient's fever and elevated heart rate, which may suggest dehydration or the need for increased fluid intake to support hemodynamic stability and mitigate the effects of fever and potential dehydration from fever and nausea.
B. Given the diagnosis of Pneumocystis pneumonia, the patient will likely be on or start antibiotics specific to this infection, such as trimethoprim-sulfamethoxazole. Monitoring for adverse reactions is crucial, especially in a newly diagnosed HIV-positive patient who might be starting multiple new medications.
C. While it is important to monitor CD4 counts in HIV-positive patients to guide treatment decisions, repeating the CD4 count immediately might not be prioritized unless there are specific clinical changes that suggest a rapid decline in immune function. Given the recent test results showing a CD4 count of 443 cells/mm^3, immediate retesting might not be clinically justified unless guided by other symptoms or considerations not detailed here.
D. Pneumocystis pneumonia does not require airborne isolation as it is not typically contagious between people under normal circumstances. Instead, it arises as an opportunistic infection in individuals with weakened immune systems. Hence, this order would not be appropriate unless there were other infections suspected that require such precautions.
E. The patient reports severe nausea, which not only is distressing but can also prevent the patient from taking oral medications and maintain necessary nutrition. Administering an antiemetic can help manage this symptom effectively.
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