A nurse is planning care for a client with a newly inserted peripherally inserted central catheter (PICC). Which interventions should the nurse include in the plan of care? Select all that apply.

Ensure a chest x-ray is used to verify correct placement of the PICC before use.

Apply a sterile dressing to the insertion site per facility protocol.

Schedule daily blood draws from the PICC line to maintain patency.

Flush the PICC line with 0.9% sodium chloride before and after use.

Monitor the insertion site for signs of infection, phlebitis, or infiltration.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:
A chest x-ray is required before using a PICC line to ensure proper placement and prevent complications such as pneumothorax or malposition, which could result in ineffective therapy or injury.

Choice B reason:
Applying a sterile dressing per facility protocol prevents infection at the insertion site and maintains catheter integrity. This is critical for preventing bloodstream infections.

Choice C reason:
Scheduling daily blood draws from the PICC is unnecessary and may increase the risk of infection. Blood should only be drawn as clinically indicated.

Choice D reason:
Flushing the PICC line with 0.9% sodium chloride before and after each use maintains patency, prevents clot formation, and ensures the line remains functional for medication administration or fluid therapy.

Choice E reason:
Regular monitoring of the insertion site for redness, swelling, pain, or discharge allows early identification of infection, phlebitis, or infiltration, ensuring timely intervention and client safety.

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 A

Explanation

Choice A reason:
Clostridium difficile infection commonly causes severe diarrhea, which can lead to excessive loss of fluids and electrolytes such as sodium, potassium, and bicarbonate. This fluid and electrolyte loss significantly increases the risk of dehydration and electrolyte imbalance, making it the most likely cause.

Choice B reason:
Parkinson's disease is a neurological disorder that affects movement and motor control. While it may indirectly impact nutrition or hydration in advanced stages, it is not a direct or common cause of acute electrolyte imbalance associated with dehydration.

Choice C reason:
Asthma primarily affects the respiratory system and does not typically cause significant fluid or electrolyte losses. Unless complicated by other factors, asthma alone is unlikely to result in dehydration-related electrolyte imbalance.

Choice D reason:
Hypertension is a chronic cardiovascular condition characterized by elevated blood pressure. By itself, it does not directly cause dehydration or electrolyte imbalance unless influenced by factors such as diuretic use, which are not specified in the question.

A. Teaching a client how to self-administer insulin. B. Performing sterile wound care for a postoperative client. C. Assisting a stable client with ambulation to the bathroom. D. Assessing lung sounds in a client with pneumonia.

Correct Answer is C

Explanation

Choice A reason:
Teaching clients, especially regarding medications such as insulin, requires nursing judgment, assessment of understanding, and evaluation of learning. This responsibility falls within the scope of practice of a licensed nurse, not UAP.

Choice B reason:
Sterile wound care requires clinical judgment, assessment of the wound, and evaluation for signs of infection. These tasks are outside the scope of practice for UAP and must be performed by a licensed nurse.

Choice C reason:
Assisting a stable client with ambulation is a routine, noninvasive task that does not require nursing assessment or clinical judgment. This is an appropriate delegation to UAP, provided the client is stable and mobility assistance has been deemed safe.

Choice D reason:
Assessing lung sounds involves interpretation of clinical findings and evaluation of respiratory status, which are components of nursing assessment. This task must be performed by a licensed nurse.

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 with a newly inserted peripherally inserted central catheter (PICC). Which interventions should the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client admitted with dehydration suspected to have an electrolyte imbalance. Which finding should the nurse identify as a possible cause of electrolyte imbalance?

Correct Answer is A

Explanation

The nurse supervisor is reviewing staff assignments made during the previous shift. Which assignment should the nurse supervisor identify as appropriate to the unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

A nurse is caring for a client admitted with a fluid imbalance. Which laboratory test(s) should the nurse anticipate will be affected by the client's condition? Select all that apply.

A nurse is providing discharge education to a client who has a double-lumen peripherally inserted central catheter (PICC). The client will be receiving IV antibiotics at home with a caregiver’s assistance. Which statement by the caregiver indicates learning has been effective?

A nurse is prioritizing care for four clients. Which client should the nurse assess first?

The nurse is reviewing ethical principles that guide professional nursing practice. Which ethical principle is best defined as the obligation to avoid causing harm to a client?

The nurse assesses the client’s peripheral intravenous (IV) site and observes a red streak on the forearm that is warm to the touch. Which action should the nurse perform first?

The healthcare provider has prescribed hypotonic intravenous (IV) fluids for a client admitted with dehydration. Which solution should the nurse anticipate administering?

A nurse administers an incorrect medication to a client and does not complete an incident report because the client experienced no adverse effects. Which ethical principle did the nurse violate?

The nurse prepares to insert an intravenous line in a client. What assessment(s) should the nurse perform to ensure the IV is placed in an appropriate location? Select all that apply.