Nokea
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.
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A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
- A. The catheter has been in place for 20 hours.
- B. The client has poor vascular access in the upper extremities.
- C. The catheter is placed in the proximal tibia.
- D. The client's left lower extremity is cool to the touch.
Correct Answer: D
Rationale: A cool extremity suggests decreased blood flow, potentially indicating compartment syndrome, a critical condition that could lead to limb loss if not addressed immediately. The other findings are less urgent.
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.
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.
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 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.