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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Cerebral palsy is caused by brain injury or abnormal development, but the damage itself does not worsen over time. The severity of symptoms can vary as the child grows, but it is not progressive.

B. While CP is a permanent disability, this response does not address the client’s concern about the progression of symptoms.

C. The brain lesion in CP does not continue to develop in most cases, so this explanation would not provide accurate information.

D. Severe motor dysfunction does not solely determine the child’s outcome, as therapy and early interventions can significantly improve functional abilities.

A. Sodium intake with meals and snacks affects the blood pressure. B. Elevated blood pressure must be anticipated and identified quickly. C. Blood pressure fluctuations means that the condition has become chronic. D. Hypotension leading to sudden shock can develop at any time.

Correct Answer is B

Explanation

A. Sodium intake with meals and snacks affects the blood pressure. While sodium can contribute to blood pressure increases, the primary reason for monitoring blood pressure in this case is to detect the kidney-related hypertension.

B. Elevated blood pressure must be anticipated and identified quickly. Blood pressure can increase significantly in acute glomerulonephritis due to fluid retention and kidney impairment. Frequent monitoring helps to identify and treat elevated blood pressure early, preventing complications.

C. Blood pressure fluctuations mean that the condition has become chronic. Acute glomerulonephritis typically causes fluctuating blood pressure, but this does not necessarily indicate chronic disease.

D. Hypotension leading to sudden shock can develop at any time. Hypotension is less common in acute glomerulonephritis compared to hypertension, making this response less accurate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Correct Answer is A

Explanation

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Correct Answer is B

Explanation

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

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?

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

Which client should the charge nurse on the oncology unit assign to a registered nurse (RN), rather than a practical nurse (PN)?

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?