week 7 prepzU

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? A. Apply pressure to insertion site for at least 3 minutes B. Ask the client to perform Valsalva maneuver C. Instruct client to remain flat for 30 minutes D. Apply pertoleum-based ointment and sterile occlusive dressing

A. Apply pressure to insertion site for at least 3 minutes Taylor, Nursing Fundamentals pg 1593

The nurse is preparing o administer an IV medication through a tunneled venous access device. Prior to administering an IV medication, the nurse meets resistance when attempting to flush the line with saline .What is the best action by the nurse? A. Assess for external blockage and/or clamping of the line B. Inject alteplase to de-clot the line C. Obtain a larger syringe and attempt to flush the line D. Administer heparin to de-clot the line

A. Assess for external blockage and/or clamping of the line The best action by the nurse is to assess for external kinks and/or other exterior blockages of the line such as clamping of the line. Alteplase may be appropriate if the line is clotted but requires a physician's order and the nurse should first assess for external blockage. Heparin is utilized to maintain patency of the line after flushing or medication administration. Obtaining a larger syringe may increase the pressure of the flush and rupture the central line.

The nurse is obtaining blood from a central venous access device (CVAD) using aseptic technique and during the procedure soils CVAD dressing with blood. After the sample is obtained and sent to the laboratory, what should the nurse do next? A. Change the soiled dressing per facility policy B. Call the healthcare provider regarding contamination of the CVAD dressing C. Redraw the specimen from the CVAD using sterile technique D. Reinforce the CVAD dressing

A. Change the soiled dressing per facility policy CVADs are used to obtain blood samples. Any dressing that is damp, loose, or soiled should be changed immediately and not just reinforced. Sterile procedure is not used for accessing CVADs, and the health care provider does not need to be called.

A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation? A. Reapply the dressing and notify the physician for further instructions B. Set up a sonogram for the patient the end point of the line C. Swab the line with sterile saline and gently reinsert the line D. Sedate the patient, remove the PICC line , and then notify the physician

A. Reapply the dressing and notify the physician for further instructions Taylor, Nursing Fundamentals pg. 1503

A specially changed nurse has inserted a PICC line. What would be done next? A. Send the client to the radiology department B. Explain the procedure to the client and family C. Place the client on restricted oral fluids D. Start administration of prescribed fluids

A. Send the client to the radiology department Taylor, Nursing Fundamentals 1583

The nurse is caring for children who are receiving IV therapy in the hospital setting. For which children would a central venous device be indicated? A. A child whois receiving a on-time dose of medication B. A child who is receiving chemotherapy for leukemia C. A child who is receiving an IV push D. A child who is receiving IV fluids for dehydration

B. A child who is receiving chemotherapy for leukemia maternity and pediatric nursing care pg 1226

The nurse will use a special needle to start intravenous (IV) fluids through which central venous access device? A. a peripherally inserted central catheter B. An implanted port C. a tunneled central catheter D. a multilumen catheter

B. An implanted port maternity and pediatric nursing care pg 1697

A client is receiving TPN administered through a central line. What should the nurse do to prevent complications associated with this infusion? Select all that apply A. Keep the client on strict bed rest B. Cover the insertion site with a moisture proof dressing C. Instruct the client to alert a nurse for assistance before attempting any activities of daily living D. Use aseptic technique for dressing changes E. Secure all connections of the system

B. Cover the insertion site with a moisture proof dressing D. Use aseptic technique for dressing changes E. Secure all connections of the system Complications associated with administration of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an occlusive dressing, and all connections of the system must be secure. Ambulation and activities of daily living are encouraged and not limited during the administration of TPN.

A client is in the hospital with a peripherally inserted central catheter (PICC) in the right arm and is suspected of becoming septic. The nurse has to get a blood culture from this client. What is the best practice for this procedure? A. Administer an IV antibiotic and then get a blood culture B. Obtain a peripheral blood culture from the left arm C. Get the blood culture from the central line D. Obtain a peripheral blood culture from the right arm

B. Obtain a peripheral blood culture from the left arm Blood cultures in a septic client should be performed peripherally instead of from the central line because the central line could be the source of infection. Blood specimens and blood pressures should not be obtained on the extremity with the PICC line. Blood cultures should be performed before antibiotics are given to prevent a false negative result. Therefore, a blood culture from the left arm in this client would be the best practice.

When administering an IV medication. through a central line, the nurse notes that a client's central line gauze dressing was last changed 24 hours previously. What is the appropriate action by the nurse? A. Contact the healthcare provider B. Proceed to administer the IV medication C. Complete an incident report D. Change the central line dressing

B. Proceed to administer the IV medication Gauze dressings should be changed every 2 days so the nurse should proceed to administer the medication. There is no need for an incident report or to contact the healthcare provider.

A client with diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? A. a peripheral venous catheter inserted to the cephalic vein B. A midline peripheral catheter C. An implanted central venous access device (CVAD) D. A peripheral venous catheter inserted to the ante-cubital fossa

C. An implanted central venous access device (CVAD) Taylor, Nursing Fundamentals pg. 1583

What is one advantage of an implanted port (central venous access drive) that the nurse will explain to an adolescent? A. No special procedure is nessacary for removal B. Flushing of the device is not nessacary C. No tunneling is needed when the port is inserted D. Body appearance changes very little

D. Body appearance changes very little maternity and pediatric nursing care pg 1697

A client who has just had a triple-lumen catheter placed in their right subclavian vein complains of chest pain and shortness of breath. The client's blood pressure is decreased from baseline and, on auscultation of the chest, the nurse notes unequal breath sounds .A chest X-Ray is immediately ordered by the physician. What diagnosis should the nurse suspect? A. Pulmonary embolism B. heart failure C. myocardial infarction (MI) D. Pneumothorax

D. Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

A client with a central venous catheter suddenly begins to experience chest pain, dyspnea, tachypenia, and hypoxia when the nurse attempts to flush the line. Place the action in the order in which the nurse will perform them. All options must be used A. contact the health care provider B. position cline ton left side with head lower than feet C. administer oxygen D. clamp the catheter

D. clamp the catheter B. position cline ton left side with head lower than feet C. administer oxygen A. contact the health care provider