Nokea
A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.)
- A. Phlebitis
- B. Pneumothorax
- C. Thrombophlebitis
- D. Excessive bleeding
- E. Extravasion
Correct Answer: A,C
Rationale: Phlebitis and thrombophlebitis are common PICC complications. Pneumothorax is associated with subclavian catheters, not PICCs, and excessive bleeding and extravasation are less common.
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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 is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
- A. Redness at the catheter insertion site
- B. Report of headache and stiff neck
- C. Temperature of 101.1°F (37.8°C)
- D. Pain rating of 8 on a scale of 0 to 10
Correct Answer: B
Rationale: Headache and stiff neck, especially with a fever, may indicate meningitis, a life-threatening complication of epidural therapy requiring immediate intervention. Redness, fever, and high pain levels are concerning but less urgent.
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 assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
- A. Apply cold compresses to the IV site.
- B. Elevate the extremity on a pillow.
- C. Flush the catheter with normal saline.
- D. Stop the infusion of intravenous fluids.
Correct Answer: D
Rationale: Edema and tenderness suggest infiltration or phlebitis, requiring immediate cessation of the infusion to prevent further tissue damage. Flushing could worsen the issue, and cold compresses or elevation are secondary actions.
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.