A nurse is caring for a client who has a peripherally inserted central catheter (PICC) for the administration of total parenteral nutrition (TPN). The transparent dressing over the insertion site requires replacement. Which of the following actions should the nurse take?

Aspirate the catheter to check for a brisk blood return.

Use sterile technique for the procedure.

Cleanse the insertion site with hydrogen peroxide.

Flush the TPN port with 20 mL of 0.9% sodium chloride.

Answer and Explanation

The Correct Answer is B

Choice A reason: Aspirating the catheter to check for a brisk blood return is not typically recommended as a routine action when replacing the dressing of a PICC line used for TPN. This action is performed to verify patency and placement of the catheter, but it is not directly related to the dressing change procedure.

Choice B reason: Using sterile technique for the procedure is essential when replacing the dressing of a PICC line. Maintaining sterility is crucial to prevent infection, as the PICC line provides direct access to the central venous system. The nurse should use sterile gloves and follow aseptic protocols to minimize the risk of introducing pathogens at the catheter insertion site.

Choice C reason: Cleansing the insertion site with hydrogen peroxide is not recommended for PICC line care. Hydrogen peroxide can be damaging to the tissue and may delay healing. Instead, a chlorhexidine-based antiseptic is typically used to clean the skin around the insertion site during dressing changes to reduce microbial flora and prevent infection.

Choice D reason: Flushing the TPN port with 20 mL of 0.9% sodium chloride is a practice used to maintain catheter patency, but it is not part of the dressing change procedure. Flushing is usually done before and after administering medication or nutrition, not specifically during a dressing change.

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Correct Answer is B

Explanation

Choice A reason : Pressing down on the orbital area of the eye is not a recommended method for eliciting a response from a painful stimulus in an unresponsive patient due to the potential for injury to the eye.

Choice B reason : Pressing down on the trapezius muscle is an acceptable method for eliciting a response from a painful stimulus in an unresponsive patient. This technique is less invasive and can be performed safely to assess the patient's level of consciousness or response to pain without causing harm⁸.

Choice C reason : Using a 25-gauge needle is not an appropriate method for eliciting a response from a painful stimulus in an unresponsive patient. This could cause unnecessary harm and is not a standard practice in clinical settings.

Choice D reason : Eliciting a reflex with a reflex hammer is a method used to assess reflexes, not to elicit a response from a painful stimulus in an unresponsive patient. This tool is used to test neurological function and reflex integrity, not to assess pain response.

A. A client who has a headache following a grade 1 concussion. B. A client who has experienced brain death and is awaiting organ procurement. C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash. D. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack.

Correct Answer is C

Explanation

Choice A reason: A headache following a grade 1 concussion, while requiring monitoring, does not typically necessitate immediate proximity to the nurses' station. Grade 1 concussions are considered mild and usually do not involve loss of consciousness.

Choice B reason: A client who has experienced brain death and is awaiting organ procurement will not benefit from being close to the nurses' station due to the irreversible nature of brain death. The care for such a client is focused on maintaining organ viability for transplantation.

Choice C reason: A client with a score of 10 on the Glasgow Coma Scale following a motor vehicle crash should be placed closest to the nurses' station. A GCS score of 10 indicates a moderate level of impairment in consciousness and potentially unstable vital signs, requiring close monitoring and rapid nursing intervention.

Choice D reason: A score of 0 on the NIH Stroke Scale indicates no observable neurological deficit. Clients with a transient ischemic attack (TIA) and a score of 0 would require less intensive observation compared to those with higher scores or other acute neurological injuries.

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A nurse is caring for a client who has a peripherally inserted central catheter (PICC) for the administration of total parenteral nutrition (TPN). The transparent dressing over the insertion site requires replacement. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would:

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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