Nokea
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication. Based on the information provided, which action should the nurse take?
- A. Notify the health care provider
- B. Administer the prescribed medication.
- C. Discontinue the PICC.
- D. Switch the medication to the oral route.
Correct Answer: B
Rationale: The PICC is intact, patent, and free from complications, indicating it is safe to administer the prescribed IV medication. No other actions are warranted based on the provided information.
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A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the bloodstream infection?
- A. Initiate a dedicated team to insert access devices.
- B. Require additional education for all nurses.
- C. Limit the use of peripheral venous access devices.
- D. Perform quality control testing on skin preparation products.
Correct Answer: A
Rationale: A dedicated IV team reduces complications, including bloodstream infections, improving outcomes. Education is helpful but less impactful, and limiting peripheral devices or testing products is less effective.
A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this client's teaching?
- A. Avoid carrying your grandchild with the arm that has the central catheter.
- B. Be sure to place the arm with the central catheter in a sling during the day.
- C. Flush the peripherally inserted central catheter line with normal saline daily.
- D. You can use the arm with the central catheter for most activities of daily living.
Correct Answer: A
Rationale: A properly placed PICC allows considerable freedom of movement, but heavy lifting, such as carrying a grandchild, can dislodge the catheter or occlude the lumen. A sling is not necessary, and flushing is typically done with heparin, not normal saline.
A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.)
- A. Include a review for the need of the device each day in the client's plan of care.
- B. Remind the provider to perform hand hygiene prior to starting the procedure.
- C. Cleanse the preferred site with alcohol and let it dry completely before insertion.
- D. Ask everyone in the room to wear a surgical mask during the procedure.
- E. Plan to complete a sterile dressing change on the device every day.
Correct Answer: A,B,D
Rationale: To prevent infections, daily review of device necessity, hand hygiene, and surgical masks during insertion are critical. Alcohol cleansing must include chlorhexidine for effectiveness, and daily dressing changes are not standard.
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
- A. Amount of pressure in fluid container
- B. Date of catheter tubing change
- C. Percent of heparin in infusion container
- D. Presence of an ulnar pulse
Correct Answer: D
Rationale: An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. The other assessments are relevant but secondary to ensuring circulation.
A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
- A. Administer a sublingual nitroglycerin tablet.
- B. Prepare to assist with chest tube insertion.
- C. Place a sterile dressing over the IV site.
- D. Re-position the client into the Trendelenburg position.
Correct Answer: B
Rationale: Chest pain and dyspnea during subclavian catheter insertion suggest a pneumothorax, a serious complication requiring chest tube insertion. Nitroglycerin is inappropriate, and neither a sterile dressing nor Trendelenburg position addresses the pneumothorax.