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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Correct Answer is B

Explanation

A) Use chemical restraints at bedtime:
Using chemical restraints, such as sedative medications, to manage wandering behavior in clients with dementia should be avoided due to potential side effects and ethical concerns. Chemical restraints can increase the risk of falls, confusion, and other adverse effects, and should only be considered as a last resort under strict medical supervision.

B) Use a bed alarm:
A bed alarm is a practical and non-invasive intervention to help monitor a client with dementia who has a history of wandering. The alarm alerts staff when the client attempts to leave the bed, allowing for immediate response to prevent wandering and potential injury. This method promotes safety while respecting the client’s autonomy.

C) Move client to a double room:
Moving a client with dementia to a double room might not be beneficial and could potentially increase confusion and agitation. Sharing a room with another client might not address the issue of wandering and could disrupt both clients' rest and well-being. A more controlled environment is preferable.

D) Encourage participation in activities that provide excessive stimulation:
Encouraging activities with excessive stimulation can exacerbate agitation and restlessness in clients with dementia. It's important to engage them in calming and structured activities that promote a sense of routine and security, rather than overwhelming them with excessive stimuli which might increase the risk of wandering.

A. Furosemide B. Nitroprusside C. Desmopressin D. Epinephrine

Correct Answer is C

Explanation

A. Furosemide:
Furosemide is a diuretic used to promote the excretion of excess fluid in conditions such as heart failure, renal impairment, and hypertension. Given the client's already high urinary output, administering furosemide would exacerbate the fluid loss and dehydration, making it inappropriate for this scenario.

B. Nitroprusside:
Nitroprusside is a potent vasodilator used to manage hypertensive emergencies by lowering blood pressure. It does not address the issue of excessive urinary output or thirst associated with brainstem contusion, and thus, it is not suitable for treating the client's condition.

C. Desmopressin:
Desmopressin is an antidiuretic hormone (ADH) analog used to treat conditions such as diabetes insipidus, which is characterized by excessive thirst and high urinary output. The client's symptoms suggest central diabetes insipidus, likely due to brainstem injury affecting ADH production. Desmopressin would help reduce urinary output and alleviate thirst, making it the most appropriate choice.

D. Epinephrine:
Epinephrine is a medication used primarily in emergencies such as anaphylaxis, cardiac arrest, and severe asthma attacks. It does not have a role in managing high urinary output or thirst related to brainstem injury and is not relevant in this context.

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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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Naxlex Comprehensive Predictor Exams

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