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A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure?
- A. Lower the extremity below the level of the heart.
- B. Apply warm compresses to the extremity.
- C. Tap the skin lightly and avoid slapping.
- D. Place a washcloth between the skin and tourniquet.
Correct Answer: D
Rationale: Placing a washcloth between the skin and tourniquet protects fragile skin in older adults. The other actions are related to vein distension but do not specifically protect the skin.
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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 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 home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication. Based on the information provided, which action should the nurse take?
- A. Notify the health care provider
- B. Administer the prescribed medication.
- C. Discontinue the PICC.
- D. Switch the medication to the oral route.
Correct Answer: B
Rationale: The PICC is intact, patent, and free from complications, indicating it is safe to administer the prescribed IV medication. No other actions are warranted based on the provided information.
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 is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?
- A. Begin the prescribed infusion via the new access.
- B. Ensure an x-ray is completed to confirm placement.
- C. Check medication calculations with a second RN.
- D. Make sure the solution is appropriate for a central line.
Correct Answer: B
Rationale: A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.