Nokea
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.
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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.
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 prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/ml. Which of the syringe shown below should the nurse use to draw up and administer the heparin?
- A. 1-ml syringe
- B. 3-ml syringe
- C. 5-ml syringe
- D. 10-ml syringe
Correct Answer: D
Rationale: A 10-ml syringe is required for flushing PICC lines to avoid high pressure that could rupture the catheter. Smaller syringes generate higher pressure, increasing the risk of damage.
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.