NURS 455- Exam 1 Class Quizzes with answers

NURS 455- Exam 1 Class Quizzes with |\ |\ |\ |\ |\ |\ |\




answers

A nurse is caring for a client who is receiving total parenteral
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nutrition via a peripherally inserted central catheter (PICC). When
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assessing the client, the nurse notes swelling of the client's arm
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above the PICC insertion site. Which of the following actions
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should the nurse take first? |\ |\ |\ |\




A. Measure the circumference of both upper arms.
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B. Apply a cold pack to the client's upper arm.
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C. Remove the PICC line.
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D. Notify the provider who inserted the PICC line. - CORRECT
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ANSWERS ✔✔A |\ |\




Feedback: The first action the nurse should take using the |\ |\ |\ |\ |\ |\ |\ |\ |\ |\


nursing process is to assess the client. The nurse should measure
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the arm and compare the result with the circumference of the
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other arm. If the arm is swollen, the nurse should notify the
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provider who inserted the PICC line. Swelling could indicate
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formation of a clot above the site or even catheter rupture.
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A nurse is caring for a client who has a central venous catheter
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and develops acute shortness of breath. Which of the following
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actions should the nurse take first?
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A. Clamp the catheter.
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B. Position the client in left lateral Trendelenburg.
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,C. Auscultate breath sounds.
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D. Initiate oxygen therapy. - CORRECT ANSWERS ✔✔A
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Feedback: The greatest risk to this client is injury from further air
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entering the central venous catheter; therefore, the first action
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the nurse should take is to clamp the catheter.
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A nurse is caring for a client who has a central venous catheter
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and suddenly develops chest pain, dyspnea, dizziness, and
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tachycardia. The nurse suspects air embolism and clamps the |\ |\ |\ |\ |\ |\ |\ |\ |\


catheter immediately. What other action should the nurse take at
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this time?
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A. Replace the infusion system.
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B. Place the client on his left side in Trendelenburg position.
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C. Prepare for chest tube insertion.
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D. Remove the catheter. - CORRECT ANSWERS ✔✔B
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Feedback: This position helps trap the air in the apex of the right
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atrium rather than allowing it to enter the right ventricle and
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move to the pulmonary arterial system.
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A nurse is teaching a client who is about to undergo the insertion
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of a nontunneled central venous access device. Which of the
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following statements should the nurse identify as an indication
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that the client understands the instructions?
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A. "I will call the clinic if I have persistent hiccups."
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B. "I will turn my head in the opposite direction during insertion."
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, C. "I will have to stay in bed for several hours after the
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procedure."
D. "I will need to hold my breath when they first put the needle
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in." - CORRECT ANSWERS ✔✔B
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Feedback: The client should turn his head away from the |\ |\ |\ |\ |\ |\ |\ |\ |\ |\


insertion site to allow optimal accuracy in placing the catheter.
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A nurse is caring for client who has a single lumen central venous
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catheter. Which of the following actions should the nurse take
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when accessing the catheter? |\ |\ |\




A. Apply firm pressure to the syringe plunger when flushing the
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lumen.
B. Use clean technique when accessing the catheter.
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C. Flush the lumen with sterile water after each use.
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D. Use a 10-mL syringe to flush the catheter. - CORRECT
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ANSWERS ✔✔D |\




Feedback: During the flushing procedure, the nurse should use a
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10-mL barrel syringe, because the pressure that is exerted by
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smaller barrel syringes increases the risk for rupturing the
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catheter.


A client has a right subclavian central venous catheter. When
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reconnecting a new administration set, which of the following |\ |\ |\ |\ |\ |\ |\ |\ |\


instructions should the nurse give the client? |\ |\ |\ |\ |\ |\




A. "Bear down while holding breath."
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B. "Turn head to the right."
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