A nurse is obtaining a blood specimen from a client who has a peripherally inserted central catheter. Which of the following actions should the nurse take?

Use a 3 mL syringe to flush the catheter.

Cleanse the port with povidone-iodine prior to obtaining the specimen.

Flush with 20 mL of 0.9% sodium chloride after obtaining the blood sample.

Instruct the client to perform the Valsalva maneuver during the blood draw.

Answer and Explanation

The Correct Answer is D

A. Use a 3 mL syringe to flush the catheter: Small syringes (3 mL) create high pressure that can damage the lumen of a peripherally inserted central catheter (PICC). Larger syringes, typically 10 mL or greater, are recommended to safely flush and maintain catheter integrity.

B. Cleanse the port with povidone-iodine prior to obtaining the specimen: Current guidelines recommend using an alcohol-based antiseptic (e.g., 70% isopropyl alcohol) rather than povidone-iodine for cleaning catheter hubs due to faster action and reduced contamination risk.

C. Flush with 20 mL of 0.9% sodium chloride after obtaining the blood sample: While flushing is required, the volume depends on the protocol and whether blood was drawn for lab testing. Immediate flushing with 10 mL is often sufficient; 20 mL may be excessive unless the protocol specifies.

D. Instruct the client to perform the Valsalva maneuver during the blood draw: Performing the Valsalva maneuver increases intrathoracic pressure and reduces the risk of air embolism when accessing a central line. This is a recommended safety measure during blood draws from PICC lines.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Diarrhea: Diarrhea is not a common adverse effect of clozapine. Gastrointestinal symptoms may occur with some antipsychotics, but diarrhea is not a primary concern with clozapine therapy.

B. Hypoglycemia: Clozapine is more commonly associated with hyperglycemia and increased risk of diabetes mellitus, rather than hypoglycemia. Blood glucose monitoring may be needed in clients at risk.

C. Agranulocytosis: Clozapine can cause severe neutropenia or agranulocytosis, which increases the risk of infection. Regular monitoring of white blood cell counts is essential, and any signs of infection should prompt immediate evaluation.

D. Urinary frequency: Urinary frequency is not a typical adverse effect of clozapine. Anticholinergic effects like urinary retention are more commonly associated with this medication, rather than increased frequency.

A. Position the newborn on their abdomen after feeding. B. Place the newborn on a rigid feeding schedule. C. Offer the newborn a pacifier after feedings D. Burp the newborn several times during the feeding

Correct Answer is D

Explanation

A. Position the newborn on their abdomen after feeding: Placing a newborn on their abdomen after feeding increases the risk of aspiration and sudden infant death syndrome (SIDS). The recommended position after feeding is upright or on their back when sleeping.

B. Place the newborn on a rigid feeding schedule: Strict feeding schedules can lead to overfeeding or underfeeding, both of which can increase spit-up. Feeding on demand or according to the newborn’s hunger cues is safer and helps minimize gastrointestinal discomfort.

C. Offer the newborn a pacifier after feedings: Using a pacifier may soothe the newborn but does not reduce the incidence of spit-up. It is unrelated to gastric emptying or swallowing air during feeding.

D. Burp the newborn several times during the feeding: Frequent burping helps release swallowed air, which can decrease gastric distention and reduce spit-up. This technique is an effective intervention to minimize discomfort and regurgitation in formula-fed newborns.

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A nurse is obtaining a blood specimen from a client who has a peripherally inserted central catheter. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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