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.

None

Answer and Explanation

The Correct Answer is C

A.   You cannot leave a client with an open central venous access. You must secure your current client first.

B.   Calling for an assistant allows the nurse to ensure the PICC removal is completed safely while also responding to the emergency situation.
C.   Once a PICC line removal has started, the integrity of the venous system is compromised. Leaving a partially removed catheter or an untended insertion site poses immediate, life-threatening risks to the client, such as air embolism- if the catheter is partially withdrawn and the site is not occluded, atmospheric air can be sucked into the venous circulation during inspiration. If the nurse moves too quickly or awkwardly to leave, there is a risk of the catheter snapping or fraying (catheter embolism). Central venous pressure, though lower than arterial pressure, still requires focused manual pressure and an occlusive dressing immediately upon removal to prevent significant bleeding. While a Code Blue is a maximum priority, the nurse is already engaged in a high-stakes procedure. The UAP who was ambulating the patient is expected to stay with the collapsed client and call for help. Other available staff on the unit will respond to the code.
D.   Closing the room door is not relevant to managing either situation safely.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. An ionized calcium level significantly above the reference range can lead to cardiac dysrhythmias and requires immediate attention to assess cardiac function.
B. While urine output and characteristics are important indicators of renal function, cardiac assessment takes priority due to the potential cardiac effects of hypercalcemia.
C. Assessment of deep tendon reflexes is relevant since hypercalcemia can lead to muscle weakness and diminished reflexes. However, this should be done after assessing for any cardiac dysrhythmias.
D. Comparing muscle strength bilaterally is important for assessing neurological integrity but is not the priority when hypercalcemia is suspected.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D","dropdown-group-3":"F"}

Explanation

Pain relief: One of the primary goals and indications of effective epidural anesthesia is significant reduction or elimination of pain associated with labor contractions, as reflected in the patient asking for and receiving the epidural to manage increasing pain levels.
Progression of labor: Effective epidural anesthesia should allow the labor to progress without adding undue stress or causing significant delays. Monitoring cervical dilation and effacement as well as the baby's descent (station) helps determine if labor is progressing normally even after epidural administration.
Vital signs: Stable vital signs are important indicators that the epidural anesthesia is not causing adverse effects such as severe hypotension or bradycardia, which can sometimes occur with regional anesthesia due to the blockade of sympathetic nerves. Regular monitoring and stability of these signs are crucial for demonstrating effective and safe epidural anesthesia management.

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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

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

Correct Answer is A

Explanation

Exhibits Drag from the word choices to complete the sentence The client demonstrates effective epidural anesthesia by and ,

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D","dropdown-group-3":"F"}

Explanation

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