A nurse is caring for a client who has an indwelling urinary catheter.
Which of the following actions should the nurse take to prevent infection?

Complications of central venous access include thrombosis and malpositioning. Assessing localized edema requires objective measurement to quantify the extent of the vascular compromise. Nurses must apply the nursing process by performing a comprehensive assessment before implementing interventions or notifying the medical provider.

Choice A rationale

Measuring arm circumference provides baseline data to evaluate the severity of edema and possible deep vein thrombosis. Comparing bilateral measurements allows the nurse to quantify swelling, which is a critical assessment step before reporting findings to the physician.

Choice B rationale

Notification is necessary but should occur after the nurse has gathered objective data. Providing the clinician with specific measurements of arm circumference facilitates accurate clinical decision-making regarding potential complications like venous thrombosis or catheter-related mechanical infiltration.

Choice C rationale

Nurses generally do not remove PICC lines without a specific provider order unless there is an immediate, life-threatening emergency. Early removal without assessment might destroy vital venous access unnecessarily before the underlying cause of swelling is determined.

Choice D rationale

Cold packs cause vasoconstriction, which might be contraindicated if the swelling is due to a clot or specific medications. Interventions should only follow a complete assessment and verification of the underlying cause of the localized tissue swelling.

Evaluating neurological progression in traumatic brain injury involves applying the Glasgow Coma Scale and understanding brainstem function. Recognising the shift between abnormal posturing patterns is critical for identifying descending levels of brain injury and worsening central nervous system herniation.

Choice A rationale

Improved motor response, such as moving from abnormal posturing to localizing pain or following commands, indicates neurological recovery. This reflects better integration of the motor cortex and brainstem, suggesting that the initial injury or pressure is resolving.

Choice B rationale

Decorticate posturing involves damage to the corticospinal tract, while decerebrate posturing indicates more severe damage lower in the midbrain or brainstem. Progressing from decorticate to decerebrate signals significant neurological deterioration and potential brainstem herniation.

Choice C rationale

Decreased agitation can sometimes be a positive sign of recovery or a neutral sign of sedation. It does not specifically indicate worsening neurological status unless accompanied by a significant drop in the overall level of consciousness.

Choice D rationale

Increased responsiveness to external stimuli is a hallmark of neurological improvement. It suggests that the ascending reticular activating system and cerebral cortex are becoming more functional and integrated, which is the opposite of a worsening clinical state.