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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 clients 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: The correct answer is A: "Avoid carrying your grandchild with the arm that has the central catheter." This is important because carrying a child can put strain on the arm where the catheter is inserted, increasing the risk of dislodging or damaging the catheter. It is crucial to protect the integrity of the catheter site to prevent complications such as infection or bleeding.
Choice B is incorrect because placing the arm with the central catheter in a sling during the day is unnecessary and could restrict the client's mobility and lead to discomfort.
Choice C is incorrect because flushing the PICC line with normal saline should be done by a healthcare professional and not the client themselves.
Choice D is incorrect because using the arm with the central catheter for most activities of daily living can increase the risk of accidental dislodgment or damage to the catheter. It is important to be cautious and limit certain activities to protect the catheter and maintain its function.
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You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A
nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings
blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may
be at risk for what imbalance?
- A. Hypercalcemia
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: C
Rationale: The correct answer is C: Metabolic alkalosis. Pyloric stenosis can lead to vomiting, causing loss of gastric acid and chloride ions, leading to metabolic alkalosis. Low potassium levels are common in metabolic alkalosis due to potassium shifting into cells to compensate for the alkalosis. Hypercalcemia (choice A) is not associated with pyloric stenosis. Metabolic acidosis (choice B) typically presents with low pH and bicarbonate levels. Respiratory acidosis (choice D) is caused by impaired gas exchange in the lungs, not related to pyloric stenosis.
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: The correct answer is B: Prepare to assist with chest tube insertion. Chest pain and difficulty breathing after subclavian central venous catheter insertion could indicate a pneumothorax, a potential complication. Chest tube insertion is indicated to help re-expand the lung and relieve the pressure in the thoracic cavity. This intervention takes priority over the other options because it addresses the potential life-threatening complication of a pneumothorax. Administering nitroglycerin (choice A) is not indicated for chest pain in this scenario. Placing a sterile dressing over the IV site (choice C) is not appropriate for managing chest pain and difficulty breathing. Re-positioning the client into the Trendelenburg position (choice D) is not effective in addressing a pneumothorax and may worsen the client's condition.
The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a
diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?
- A. Cimetidine
- B. Maalox
- C. Potassium chloride elixir
- D. ) Furosemide
Correct Answer: A
Rationale: The correct answer is A: Cimetidine. In metabolic alkalosis, the blood pH is elevated due to excess bicarbonate. Cimetidine is a histamine-2 receptor antagonist that can help decrease gastric acid production, which can contribute to alkalosis. Maalox (B) is an antacid used to treat acid-related conditions, not alkalosis. Potassium chloride elixir (C) is used to correct potassium imbalances, not directly related to alkalosis. Furosemide (D) is a loop diuretic used to treat fluid retention and edema, not specifically indicated for metabolic alkalosis.
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 3 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: The correct answer is D because upper extremity swelling could indicate a potential complication such as deep vein thrombosis, which is a serious condition requiring immediate attention to prevent further complications. Swelling can impede blood flow and lead to clot formation.
A: The initial site dressing being 3 days old is concerning for infection but not an immediate threat.
B: The PICC being inserted 4 weeks ago may increase infection risk but does not require immediate attention.
C: A missing securement device may increase the risk of dislodgement but is not an immediate threat compared to potential vascular compromise indicated by upper extremity swelling.
. A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his
home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to
light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of
urine is present. What is the nurses most likely explanation for the low urine output?
- A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept
in place.
- B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
- C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in
decreased urine output. - D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that
results in diminished urine output.
Correct Answer: D
Rationale: The correct answer is D. The man's elevated heart rate, anxiety, and low urine output indicate a sympathetic reaction. This reaction stimulates the renin-angiotensin-aldosterone system, leading to decreased urine output. The sympathetic response triggers the release of renin, which activates angiotensin II and aldosterone, causing vasoconstriction and water reabsorption in the kidneys, ultimately reducing urine output. Choice A is incorrect because low urine output is not solely due to urinating before arrival. Choice B is incorrect as there is no indication of traumatic brain injury or ADH deficiency. Choice C is incorrect as atrial natriuretic peptide in heart failure typically increases urine output.