The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take?
Respond to the code.
Call for an assistant
Finish the procedure.
Close the room door.
None
None
The Correct Answer is C
A. You cannot leave a client with an open central venous access. You must secure your current client first.
B. Calling for an assistant allows the nurse to ensure the PICC removal is completed safely while also responding to the emergency situation.
C. Once a PICC line removal has started, the integrity of the venous system is compromised. Leaving a partially removed catheter or an untended insertion site poses immediate, life-threatening risks to the client, such as air embolism- if the catheter is partially withdrawn and the site is not occluded, atmospheric air can be sucked into the venous circulation during inspiration. If the nurse moves too quickly or awkwardly to leave, there is a risk of the catheter snapping or fraying (catheter embolism). Central venous pressure, though lower than arterial pressure, still requires focused manual pressure and an occlusive dressing immediately upon removal to prevent significant bleeding. While a Code Blue is a maximum priority, the nurse is already engaged in a high-stakes procedure. The UAP who was ambulating the patient is expected to stay with the collapsed client and call for help. Other available staff on the unit will respond to the code.
D. Closing the room door is not relevant to managing either situation safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This task typically requires a more advanced level of clinical judgment and assessment skills, which are usually beyond the scope of practice for a PN and should be conducted by a Registered Nurse (RN).
B. Removing discontinued peripheral IV catheters is a task that falls within the scope of practice for a Practical Nurse (PN). It does not require the advanced assessment skills or judgment that some other tasks might require.
C. This involves critical thinking and clinical decision-making that are responsibilities typically reserved for an RN, as it requires integrating new information and adjusting care plans based on ongoing assessments.
D. While PNs can perform certain types of wound care, initiating sterile wound care for surgical clients often requires the advanced knowledge and assessment skills of an RN, particularly if the wound care involves evaluating surgical site integrity and potential complications.
Correct Answer is ["A","D","E","F","H"]
Explanation
A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.
G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.
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