The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding sign and symptoms of infection?

Notify the primary care provides with increased urine output

Assess daily for redness. swelling or exudate at insertion site weekly

The primary care provider will monitor hemoglobin and a hematocrit values

To maintain patency, the catheter should be flushed weekly using at 5ml syringe

Answer and Explanation

The Correct Answer is B

A) Notify the primary care provider with increased urine output
Increased urine output is not directly related to signs or symptoms of infection associated with a tunneled IV catheter, such as a Hickman catheter. While changes in urinary output might indicate renal or other systemic issues, they do not signal a local infection at the insertion site.

B) Assess daily for redness, swelling, or exudate at insertion site weekly
One of the most common complications of a tunneled IV catheter, such as a Hickman, is infection at the insertion site or along the catheter tract. The nurse should instruct the patient to monitor for signs of infection, including redness, swelling, and exudate (pus or drainage) at the insertion site. These signs suggest possible infection, and early detection is critical to preventing more serious complications like sepsis.

C) The primary care provider will monitor hemoglobin and hematocrit values
While monitoring hemoglobin and hematocrit values is important for assessing overall health and blood status, it is not specifically related to monitoring for infection in a client with a tunneled IV catheter. Hemoglobin and hematocrit can provide information about anemia or dehydration but do not directly indicate an infection at the insertion site.

D) To maintain patency, the catheter should be flushed weekly using a 5ml syringe
Although flushing a tunneled IV catheter to maintain patency is important, this response does not directly address infection prevention, which is the focus of the question. Typically, a catheter should be flushed as per specific guidelines (which may include daily or weekly flushing, depending on the clinical setting).

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Correct Answer is C

Explanation

A) Equal but sluggishly reactive pupils:
Pupillary changes, including sluggish or unequal responses, are significant signs of increasing intracranial pressure (ICP) and should be monitored closely. However, altered level of consciousness (LOC) is typically one of the earliest signs of increased ICP. The response of the pupils to light can become abnormal later, once pressure increases within the brain, particularly when brainstem function is impacted.

B) Widening pulse pressure:
A widening pulse pressure is part of Cushing’s triad, which is a late sign of increased ICP. Cushing’s triad consists of hypertension, bradycardia, and irregular respirations (often seen as Cheyne-Stokes). These changes occur in the later stages of elevated ICP as a compensatory mechanism to preserve cerebral perfusion. While this is an important finding, altered LOC would precede the development of Cushing’s triad.

C) Altered level of consciousness:
Altered level of consciousness (LOC) is typically the first and most sensitive indicator of increased ICP. As pressure increases within the skull, it compresses brain tissue and affects the brainstem, which controls basic functions like consciousness. LOC can range from mild confusion and disorientation to full loss of consciousness or coma, depending on the severity of the ICP increase.

D) Tachycardia and hypotension:
Tachycardia and hypotension can be associated with shock or other conditions, but they are not characteristic of early increased ICP. In fact, as ICP rises, the body typically responds with bradycardia (slower heart rate) and hypertension (increased blood pressure), which are part of the compensatory mechanisms.

Correct Answer is ["2.5"]

Explanation

Ordered Dose: The doctor has prescribed Diltiazem at a rate of 2.5 mg per hour. This means the patient needs to receive 2.5 milligrams of Diltiazem every hour.

Medication Concentration: The medication is supplied as 125 mg of Diltiazem in 125 mL of fluid. This translates to a concentration of 1 mg of Diltiazem per 1 mL of solution.

Since the medication concentration is 1 mg/mL, delivering 2.5 mg of Diltiazem per hour requires infusing 2.5 mL of the solution per hour.

Therefore, the nurse should set the IV pump to deliver 2.5 mL/hr of the Diltiazem solution.

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The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding sign and symptoms of infection?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?

Correct Answer is C

Explanation

A patient is to receive a continuous infusion of Diltiazem at 2.5 mg hr for Atrial fibrillation, The medication is supplied 125 mg of Diltlazem in 125 mL of IV fluid. At what rate should the nurse set the IV pump? (round to the nearest tenth)

Correct Answer is ["2.5"]

Explanation

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