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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Intubation is not the first step unless the client's respiratory status continues to deteriorate despite oxygen therapy.

B. Obtaining a sputum culture may be helpful but does not address the immediate respiratory compromise.

C. A nonrebreather mask with 100% oxygen provides high-flow oxygen and is essential for a client with worsening dyspnea and low oxygen saturation.

D. A forward-leaning position may help with breathing but does not provide the necessary oxygen support in this acute situation.

A. Effective coping with illness related anxiety B. Infection prevention related to illness C. Relief of acute pain D. A review of diet progression postoperatively E. Promotion of bowel routine F. Prevention of deep vein thrombosis (DVT) related to immobility G. Fluid volume management H. Client education about diagnosis and plan of care

Correct Answer is ["B","C","G","H"]

Explanation

A. While addressing anxiety is important, it is not the most immediate priority in the emergency setting where acute pain, potential infection, and fluid management take precedence.
B. Given the diagnosis of appendicitis, preventing infection is crucial. The client is at risk for developing an infection or sepsis if the appendix perforates, which could result in peritonitis.
C. The client is experiencing severe abdominal pain (pain rating of 9/10). Effective pain management is essential for the client’s comfort and stabilization.
D. This is more relevant post-surgery. In the emergency department, the focus should be on stabilizing the client and preparing her for surgery.
E. The client has regular bowel movements and this is not a priority in the context of acute appendicitis.
F. This is a consideration for longer-term inpatient care or post-surgery, not an immediate priority in the emergency setting.
G. The client is receiving a bolus of Lactated Ringer’s to manage her fluid volume. Maintaining adequate hydration and correcting any potential dehydration or fluid imbalance is vital.
H. Educating the client about her diagnosis and the plan of care, including the upcoming surgery, helps reduce anxiety and ensures that she is informed about her treatment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Exhibits The nurse is stabilizing the client and preparing her for surgery. What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

Correct Answer is ["B","C","G","H"]

Explanation

Exhibits Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions. Drag from the Word Choices to complete the sentence. The client demonstrates effective epidural anesthesia by dropdown, dropdown, and dropdown.

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

A client who fell and broke a wrist is admitted for 24 hour observation after emergency orthopedic surgery. The healthcare provider prescribes discharge in the morning. Which finding(s) should the nurse use to evaluate the client's status for discharge from the hospital? Select all that apply.

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

Exhibits Which laboratory tests would be helpful in determining the plan of care for this client? Select all that apply.

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?