A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the client's plan of care?

Use a 3 mL syringe to flush the PICC following infusions.

Assess the PICC infusion system systematically.

Change the needleless connector device on the IV tubing after each infusion.

Provide daily dressing changes to the PICC insertion site.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Use a 3 mL syringe to flush the PICC following infusions: A syringe smaller than 10 mL creates excessive pressure, which can damage the catheter. A 10 mL syringe or larger should always be used to flush a PICC to maintain catheter integrity.

B. Assess the PICC infusion system systematically: Systematic assessment of the PICC line, including the site, tubing, and connections, is essential for detecting complications such as infiltration, infection, or occlusion. This promotes safe and effective use of the catheter.

C. Change the needleless connector device on the IV tubing after each infusion: The needleless connector device does not need to be changed after each infusion. It is typically changed every 7 days or if contamination, leakage, or other issues are noted.

D. Provide daily dressing changes to the PICC insertion site: PICC dressings should be changed every 7 days if using a transparent dressing, or sooner if the dressing becomes damp, loose, or visibly soiled. Daily dressing changes increase infection risk unnecessarily.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Fever: While fever may occur in pericarditis due to inflammation or infection, it is not specific to cardiac tamponade. It reflects a systemic inflammatory response rather than a mechanical complication like fluid accumulation compressing the heart.

B. Atrial fibrillation: Atrial fibrillation may develop in some cardiac conditions, including pericarditis, but it is not a hallmark feature of cardiac tamponade. It does not directly reflect the hemodynamic compromise seen with tamponade.

C. Paradoxical pulse: Paradoxical pulse (pulsus paradoxus) is a key sign of cardiac tamponade. It refers to an exaggerated decrease in systolic blood pressure during inspiration, caused by restricted ventricular filling from fluid accumulation in the pericardial sac, leading to reduced cardiac output.

D. Pericardial friction rub: A pericardial friction rub is a classic finding in acute pericarditis due to inflamed pericardial surfaces rubbing together, but it is not typically heard in cardiac tamponade, where fluid accumulation muffles heart sounds.

A. Notify the surgeon of the temperature elevation. B. Encourage the client to drink more fluids. C. Assess the surgical incision for signs of infection. D. Monitor vital signs every 4 hr.

Correct Answer is C

Explanation

Rationale:
A. Notify the surgeon of the temperature elevation: While the surgeon may need to be informed if there are signs of infection or persistent fever, the nurse should first gather more data to determine the possible cause of the elevated temperature.

B. Encourage the client to drink more fluids: Increased fluid intake may help reduce mild postoperative fever, especially if it's related to dehydration or atelectasis. However, this is not the priority without assessing for infection first.

C. Assess the surgical incision for signs of infection: The priority is to assess for potential sources of infection, particularly the surgical site, given that the client is 3 days postoperative and has a fever. Early identification of infection is critical to prevent complications such as wound dehiscence or sepsis.

D. Monitor vital signs every 4 hr: Routine monitoring is important but does not take precedence over immediate assessment of the surgical site when there is a concerning temperature elevation. The nurse should act to identify the cause first.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?

Correct Answer is C

Explanation

A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The client's vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respiration 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching?

A nurse is caring for a client in the emergency department. Exhibits For each assessment finding, click to specify if the finding is consistent with myocardial infarction or angina. Each finding may support more than one disease process

A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?

A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?

80. A nurse is preparing to obtain a wound drainage specimen for culture from a client who has a nonhealing burn injury. In what order should the nurse collect this specimen? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?

A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?

A nurse is caring for a male client in the emergency department. Exhibits The nurse is planning care for this client. For each potential prescription, specify if it is anticipated or contraindicated: