Nokea
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
- A. The initial site dressing is 4 days old.
- B. The PICC was inserted 4 weeks ago.
- C. A securement device is absent.
- D. Upper extremity swelling is noted.
Correct Answer: D
Rationale: Upper extremity swelling could indicate infiltration or thrombosis, requiring immediate removal of the PICC to prevent further complications. The other findings are concerning but not as urgent.
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A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?
- A. Allergic reaction
- B. Bowel obstruction
- C. Catheter lumen occlusion
- D. Infection
Correct Answer: D
Rationale: Abdominal pain and fever suggest peritonitis, a serious infection related to intraperitoneal therapy. Allergic reactions occur earlier, and bowel obstruction or catheter occlusion present differently.
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 is calculating the infusion rate for a medication to be delivered. (Record your answer using a whole number.) drops/min
- A. 10 drops/min
- B. 12 drops/min
- C. 14 drops/min
- D. 16 drops/min
Correct Answer: D
Rationale: The correct infusion rate is 16 drops/min, as specified in the document.
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 is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
- A. Administer topical lidocaine to the site.
- B. Place warm compresses on the site.
- C. Administer prescribed oral pain medication.
- D. Massage the site with scented oils.
Correct Answer: B
Rationale: Warm compresses help relieve pain from phlebitis after catheter removal. Lidocaine, oral medication, and massage are not standard treatments for this condition.