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.

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Correct Answer is D

Explanation

Rationale:
A. The client will be on bed rest while continuous bladder irrigation is in place.: Bed rest is not required solely due to continuous bladder irrigation (CBI). Early ambulation is encouraged postoperatively to prevent complications such as deep vein thrombosis and promote recovery.

B. Cold compresses will be used to manage bladder spasms.: Bladder spasms are common after prostate surgery, but they are typically managed with anticholinergic medications, such as oxybutynin, rather than cold compresses.

C. The client will have an NG tube in place for 48 hr postoperatively.: An NG tube is not routinely used following a radical prostatectomy unless the client develops complications like ileus or vomiting. Its use is not part of standard postoperative care.

D. A PCA pump will be used for postoperative pain control.: A patient-controlled analgesia (PCA) pump is commonly used after major surgeries like a radical prostatectomy to manage pain effectively. It allows the client to self-administer controlled doses of pain medication for optimal comfort.

A. Hypotension B. Flattened jugular veins C. Lethargy D. Bounding pulse

Correct Answer is D

Explanation

Rationale:
A. Hypotension: Circulatory overload typically causes hypertension rather than hypotension due to increased blood volume and pressure. Hypotension would be more consistent with a different transfusion reaction such as anaphylaxis or septic shock.

B. Flattened jugular veins: Jugular vein distention, not flattening, is a classic sign of circulatory overload. Distended neck veins indicate elevated central venous pressure from fluid excess.

C. Lethargy: While lethargy may occur with various conditions, it is not a specific or early sign of circulatory overload. More immediate symptoms include respiratory distress and cardiovascular changes.

D. Bounding pulse: A bounding pulse is a key sign of circulatory overload, reflecting increased stroke volume and elevated intravascular volume. It often occurs alongside hypertension, dyspnea, and jugular vein distention, especially in older adults with compromised cardiac function.

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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

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