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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.
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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 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 registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.)
- A. State Nurse Practice Act
- B. The facility's Policies and Procedures
- C. The LPN's level of education and experience
- D. The Joint Commission's goals and criterion
- E. Client needs and prescribed orders
Correct Answer: A,B
Rationale: The State Nurse Practice Act and facility policies guide delegation, as they outline LPN scope of practice. Other factors like experience and client needs are considered but are not primary standards.
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.