A nurse is planning care for a client who requires insertion of a peripherally inserted central catheter (PICC) line. Which of the following actions should the nurse plan to take?

Use a 3 ml syringe when flushing the PICC line.

Flush the PICC line with 0.9% sodium chloride after medication administration.

Expect the PICC line to be inserted into a lower extremity vein.

Monitor for a pneumothorax following insertion of the PICC line.

Answer and Explanation

The Correct Answer is B

A) Use a 3 ml syringe when flushing the PICC line:
Using a 3 ml syringe for flushing is not recommended. Smaller syringes generate higher pressure, which can damage the catheter. Instead, a 10 ml syringe is typically used to flush PICC lines to ensure safe pressure levels.
B) Flush the PICC line with 0.9% sodium chloride after medication administration:
Flushing the PICC line with 0.9% sodium chloride after medication administration is standard practice. It helps clear the line of any residual medication, preventing drug interactions and ensuring the line remains patent.
C) Expect the PICC line to be inserted into a lower extremity vein:
PICC lines are typically inserted into veins in the upper extremities, such as the basilic, brachial, or cephalic veins, rather than lower extremity veins. This positioning reduces the risk of complications and allows for better access and care.
D) Monitor for a pneumothorax following insertion of the PICC line:
Monitoring for a pneumothorax is not typically necessary following PICC line insertion. Pneumothorax is a potential complication of central venous catheter placements involving the subclavian or jugular veins, not the peripheral veins used for PICC lines. Instead, complications like infection, thrombosis, and catheter occlusion are more relevant concerns.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A) "I will check my pulse before I take the medication":
While checking the pulse is important for certain medications, it is not a primary concern for furosemide. Furosemide is a diuretic used to manage fluid overload, and its key adverse effects are related to electrolyte imbalances and dehydration rather than changes in heart rate.

B) "I will try to limit foods that contain salt":
Limiting salt intake is a relevant dietary adjustment for clients with heart failure, but it is not directly related to the adverse effects of furosemide. Furosemide works by increasing urine output and can lead to electrolyte imbalances, but salt restriction is more about overall management of heart failure rather than a specific adverse effect of the medication.

C) "I'm going to include more cantaloupe in my diet":
Cantaloupe is high in potassium, which is relevant for clients taking furosemide. Furosemide can cause potassium depletion, so increasing potassium-rich foods is an important measure to help prevent hypokalemia, a common adverse effect of this medication.

D) "I check my blood pressure so it doesn't get too high":
While monitoring blood pressure is important, the primary concern with furosemide is related to electrolyte imbalances and dehydration rather than blood pressure management. Furosemide can cause fluid loss, which may impact blood pressure, but the direct adverse effect of concern is electrolyte imbalance, particularly potassium levels.

A. Assist the client with toileting at least once every 4 hr. B. Turn off all lights in the client's room at night. C. Place the client's bed at the lowest height. D. Request a prescription for a nightly sedative.

Correct Answer is C

Explanation

A) Assist the client with toileting at least once every 4 hr:
Assisting the client with toileting every 4 hours can help prevent incontinence and associated skin issues, but the frequency should be tailored to the client's individual needs. A rigid schedule may not be necessary and could cause unnecessary disturbances. Personalized care plans based on the client's toileting habits and preferences are more effective.

B) Turn off all lights in the client's room at night:
Turning off all lights at night can lead to increased disorientation and risk of falls for a client with dementia. A better approach is to use a nightlight or low-level lighting to maintain safety and provide enough illumination for the client to navigate the room if they wake up. This helps balance restfulness and safety.

C) Place the client's bed at the lowest height:
Placing the client's bed at the lowest height is a critical safety measure to reduce the risk of injury from falls, which are common in clients with dementia. It makes it easier for the client to get in and out of bed safely and minimizes the potential for serious injury if a fall does occur. This intervention is straightforward and highly effective in enhancing client safety.

D) Request a prescription for a nightly sedative:
Requesting a nightly sedative should be considered only after exploring non-pharmacological interventions for sleep disturbances. Sedatives can have significant side effects, including increased confusion and fall risk. Behavioral strategies, environmental modifications, and routine establishment should be prioritized to promote better sleep hygiene for clients with dementia.

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A nurse is planning care for a client who requires insertion of a peripherally inserted central catheter (PICC) line. Which of the following actions should the nurse plan to take?

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Correct Answer is C

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Correct Answer is C

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