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 ["B","C","G","H"]

Explanation

A. While addressing anxiety is important, it is not the most immediate priority in the emergency setting where acute pain, potential infection, and fluid management take precedence.
B. Given the diagnosis of appendicitis, preventing infection is crucial. The client is at risk for developing an infection or sepsis if the appendix perforates, which could result in peritonitis.
C. The client is experiencing severe abdominal pain (pain rating of 9/10). Effective pain management is essential for the client’s comfort and stabilization.
D. This is more relevant post-surgery. In the emergency department, the focus should be on stabilizing the client and preparing her for surgery.
E. The client has regular bowel movements and this is not a priority in the context of acute appendicitis.
F. This is a consideration for longer-term inpatient care or post-surgery, not an immediate priority in the emergency setting.
G. The client is receiving a bolus of Lactated Ringer’s to manage her fluid volume. Maintaining adequate hydration and correcting any potential dehydration or fluid imbalance is vital.
H. Educating the client about her diagnosis and the plan of care, including the upcoming surgery, helps reduce anxiety and ensures that she is informed about her treatment.

A. Monitor the client's white blood cell count. B. Institute contact precautions for staff and visitors. C. Send wound drainage for culture and sensitivity. D. Explain the purpose of a low bacteria diet. E. Use standard precautions and wear a mask.

Correct Answer is ["A","B","C"]

Explanation

A. Monitor the client's white blood cell count. WBC count is a key indicator of infection and helps monitor the severity of the infection.

B. Institute contact precautions for staff and visitors. MRSA is highly contagious and can be spread through direct contact, so contact precautions are necessary to prevent transmission.

C. Send wound drainage for culture and sensitivity. This is essential to identify the specific pathogen and determine the appropriate antibiotic treatment.

D. Explain the purpose of a low bacteria diet. While a low-bacteria diet is often recommended for immunocompromised patients, it is not a priority in this scenario, where infection management and isolation precautions are more urgent.

E. Use standard precautions and wear a mask. Standard precautions should always be used, but a mask is not necessary unless the client has respiratory symptoms, which is not indicated in this case.

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse is stabilizing the client and preparing her for surgery. What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

Correct Answer is ["B","C","G","H"]

Explanation

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.

Correct Answer is ["A","B","C"]

Explanation

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Exhibits According to the lab values, the client has dropdownrelated to dropdownordropdown.

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care?

An adult is admitted with acute flank pain, a 102° F (38.9° C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.

Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?