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NCLEX FINAL Review questions
Terms in this set (11)
A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this client's teaching?
A. "Avoid carrying your grandchild with the arm that has the central catheter."
B. "Be sure to place the arm with the central catheter in a sling during the day."
C. "Flush the peripherally inserted central catheter line with normal saline daily."
D. "You can use the arm with the central catheter for most activities of daily living."
A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
A. Administer a sublingual nitroglycerin tablet.
B. Prepare to assist with chest tube insertion.
C. Place a sterile dressing over the IV site.
D. Re-position the client into the Trendelenburg position.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
A. Redness at the catheter insertion site
B. Report of headache and stiff neck
C. Temperature of 100.1° F (37.8° C)
D. Pain rating of 8 on a scale of 0 to 10
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
A. The initial site dressing is 3 days old.
B. The PICC was inserted 4 weeks ago.
C. A securement device is absent.
D. Upper extremity swelling is noted
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
A. Apply cold compresses to the IV site.
B. Elevate the extremity on a pillow.
C. Flush the catheter with normal saline.
D. Stop the infusion of intravenous fluids
While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
A. "Grade 3 phlebitis at IV site"
B. "Infection at IV site"
C. "Thrombosed area at IV site"
D. "Infiltration at IV site
A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first?
A. Check for kinking of the catheter.
B. Flush the catheter with a thrombolytic enzyme.
C. Get a new infusion pump.
D. Remove the IV catheter
A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device?
A. "Provide a bed bath instead of letting the client take a shower."
B. "Use sterile technique when changing the dressing."
C. "Disconnect the intravenous fluid tubing prior to the client's bath."
D. "Use a plastic bag to cover the extremity with the device."
A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this client's teaching?
A. "You will need to wear a sling on your arm while the device is in place."
B. "There is no risk of infection because sterile technique will be used during insertion."
C. "Ask all providers to vigorously clean the connections prior to accessing the device."
D. "You will not be able to take a bath with this vascular access device."
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
A. Administer topical lidocaine to the site.
B. Place warm compresses on the site.
C. Administer prescribed oral pain medication.
D. Massage the site with scented oils
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm." For which complication of this therapy should the nurse assess this client?
A. Allergic reaction
B. Bowel obstruction
C. Catheter lumen occlusion
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