The nurse is caring for a client with a double lumen peripherally inserted central catheter (PICC) line on the right upper extremity, that flushes easily but does not have a blood return. Normal saline is infusing through one port and a vasopressor agent is infusing through the other port.

Which intervention(s) should the nurse implement? Select all that apply.

Stop the infusions and insert an antecubital IV catheter.

Continue Infusions as long as catheter flushes easily.

Aspirate and flush the line until a blood return is obtained.

Observe the extremity for signs of infiltration.

Acquire consent for a new PICC line insertion.

Answer and Explanation

Correct Answer : B,D

A. Stopping the infusions and inserting a new catheter may not be necessary at this point unless complications develop.

B. As long as the catheter is flushing easily and the infusions are not causing complications (such as infiltration), it is appropriate to continue using it.

C. Aspirating and flushing the line until a blood return is obtained may cause damage to the catheter or further complications.

D. Monitoring for signs of infiltration is crucial, as the inability to aspirate a blood return may indicate a partial occlusion or other issues with the PICC line.

E. Replacing the PICC line may not be necessary unless more severe complications are observed.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Obtaining a 12-lead ECG is done after return of spontaneous circulation (ROSC), not during defibrillation.
B. Interrogating the pacemaker is important but is not the immediate priority during resuscitation.
C. Defibrillator pads should be placed at least 1 inch away from the pacemaker to prevent damage to the device and ensure effective defibrillation.
D. A doughnut magnet is used to deactivate pacemaker functions in cases like pacemaker-mediated tachycardia but is not relevant in ventricular fibrillation.

A. The client's daily blood pressure will be less than 140/80 mm Hg this month. B. The client's family will state signs and symptoms about the disease. C. The nurse will demonstrate the procedure for accurate eye care. D. The client will express acceptance of his changing health status.

Correct Answer is A

Explanation

A: Controlling blood pressure to less than 140/80 mm Hg is essential for reducing the risk of diabetic retinopathy, which can contribute to blurred vision and other complications.

B: Educating the family about the disease is important, but it does not directly address the client’s blurred vision or its underlying cause.

C: While eye care is important, this outcome does not focus on addressing the underlying issue of blurred vision in a client with diabetes.

D: Although acceptance of health status is important, it is not as directly related to managing the client’s vision issues as controlling blood pressure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is A

Explanation

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin- resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?