The nurse is caring for a client with a double lumen peripherally inserted central catheter (PICC) line on the right upper extremity, that flushes easily but does not have a blood return. Normal saline is infusing through one port and a vasopressor agent is infusing through the other port.

Which intervention(s) should the nurse implement? Select all that apply.

Stop the infusions and insert an antecubital IV catheter.

Continue Infusions as long as catheter flushes easily.

Aspirate and flush the line until a blood return is obtained.

Observe the extremity for signs of infiltration.

Acquire consent for a new PICC line insertion.

Answer and Explanation

Correct Answer : B,D

A. Stopping the infusions and inserting a new catheter may not be necessary at this point unless complications develop.

B. As long as the catheter is flushing easily and the infusions are not causing complications (such as infiltration), it is appropriate to continue using it.

C. Aspirating and flushing the line until a blood return is obtained may cause damage to the catheter or further complications.

D. Monitoring for signs of infiltration is crucial, as the inability to aspirate a blood return may indicate a partial occlusion or other issues with the PICC line.

E. Replacing the PICC line may not be necessary unless more severe complications are observed.

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Correct Answer is B

Explanation

A. Exenatide does not act exactly the same as insulin. It is a glucagon-like peptide-1 (GLP-1) receptor agonist, not insulin.

B. Notify your healthcare provider if you start having abdominal pain is important because abdominal pain is a known side effect of exenatide and may indicate a more serious issue like pancreatitis, which needs to be addressed promptly.

C. There are precautions when taking exenatide with other medications, especially those that affect gastrointestinal motility or glucose levels, so this statement is incorrect.

D. Exenatide should be injected within 60 minutes before a meal, not 30 minutes before or after, to optimize its effectiveness.

A. Encourage him to go to the nurse's station and talk with another nurse. B. Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client. C. Inform him that the nurse is busy admitting a new client and will talk to him later. D. Introduce him to the newly admitted client and ask him to join in the conversation.

Correct Answer is C

Explanation

A. Redirecting to another nurse does not set a clear boundary with the client.
B. Ignoring (extinction) may escalate the behavior rather than appropriately managing it.
C. Setting clear and firm boundaries helps maintain structure and prevents manipulation, which is a key component of managing clients with antisocial behavior.
D. Introducing him to the newly admitted client and asking him to join the conversation may reinforce disruptive behavior.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

Correct Answer is B

Explanation

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Correct Answer is C

Explanation

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

The nurse is preparing to administer an ampicillin suspension labeled, "Ampicillin 250 mg/5 mL," to a child with impetigo. The prescription: is for 500 mg four times a day. How many mL should the child receive per day? (Enter numeric value only.)

A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect?