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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.
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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 prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) Patient Blood coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.)
- A. Unique facility identifier
- B. Lot number related to the donor
- C. Name of the client receiving blood
- D. ABO group and Rh type of the donor
- E. Blood type of the client receiving blood
Correct Answer: A,B,D
Rationale: The ISBT system requires a unique facility identifier, lot number, product code, and ABO/Rh type of the donor. Client-specific information is not included on the blood label.
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 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'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.