NURS 455- Exam 1 Practice Questions
With Correct Answers
A nurse is caring for a client who is receiving total parenteral nutrition via a
peripherally inserted central catheter (PICC). When assessing the client, the
nurse notes swelling of the client's arm above the PICC insertion site. Which
of the following actions should the nurse take first?
A. Measure the circumference of both upper arms.
B. Apply a cold pack to the client's upper arm.
C. Remove the PICC line.
D. Notify the provider who inserted the PICC line. - ANSWER A
Feedback: The first action the nurse should take using the nursing process is
to assess the client. The nurse should measure the arm and compare the
result with the circumference of the other arm. If the arm is swollen, the
nurse should notify the provider who inserted the PICC line. Swelling could
indicate formation of a clot above the site or even catheter rupture.
A nurse is caring for a client who has a central venous catheter and develops
acute shortness of breath. Which of the following actions should the nurse
take first?
A. Clamp the catheter.
B. Position the client in left lateral Trendelenburg.
C. Auscultate breath sounds.
D. Initiate oxygen therapy. - ANSWER A
,Feedback: The greatest risk to this client is injury from further air entering
the central venous catheter; therefore, the first action the nurse should take
is to clamp the catheter.
A nurse is caring for a client who has a central venous catheter and suddenly
develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects
air embolism and clamps the catheter immediately. What other action should
the nurse take at this time?
A. Replace the infusion system.
B. Place the client on his left side in Trendelenburg position.
C. Prepare for chest tube insertion.
D. Remove the catheter. - ANSWER B
Feedback: This position helps trap the air in the apex of the right atrium
rather than allowing it to enter the right ventricle and move to the
pulmonary arterial system.
A nurse is teaching a client who is about to undergo the insertion of a
nontunneled central venous access device. Which of the following statements
should the nurse identify as an indication that the client understands the
instructions?
A. "I will call the clinic if I have persistent hiccups."
B. "I will turn my head in the opposite direction during insertion."
C. "I will have to stay in bed for several hours after the procedure."
D. "I will need to hold my breath when they first put the needle in." -
ANSWER B
Feedback: The client should turn his head away from the insertion site to
, allow optimal accuracy in placing the catheter.
A nurse is caring for client who has a single lumen central venous catheter.
Which of the following actions should the nurse take when accessing the
catheter?
A. Apply firm pressure to the syringe plunger when flushing the lumen.
B. Use clean technique when accessing the catheter.
C. Flush the lumen with sterile water after each use.
D. Use a 10-mL syringe to flush the catheter. - ANSWER D
Feedback: During the flushing procedure, the nurse should use a 10-mL
barrel syringe, because the pressure that is exerted by smaller barrel syringes
increases the risk for rupturing the catheter.
A client has a right subclavian central venous catheter. When reconnecting a
new administration set, which of the following instructions should the nurse
give the client?
A. "Bear down while holding breath."
B. "Turn head to the right."
C. "Sit in semi-Fowler's position."
D. "Exhale slowly." - ANSWER A
Feedback: The client should perform a Valsalva maneuver by holding a breath
and bearing down while the nurse disconnects the old set and reconnects the
new set. This action prevents air from entering the lumen, the heart, and
pulmonary circulation.
A nurse is caring for a client who is receiving a unit of packed red blood cells.
With Correct Answers
A nurse is caring for a client who is receiving total parenteral nutrition via a
peripherally inserted central catheter (PICC). When assessing the client, the
nurse notes swelling of the client's arm above the PICC insertion site. Which
of the following actions should the nurse take first?
A. Measure the circumference of both upper arms.
B. Apply a cold pack to the client's upper arm.
C. Remove the PICC line.
D. Notify the provider who inserted the PICC line. - ANSWER A
Feedback: The first action the nurse should take using the nursing process is
to assess the client. The nurse should measure the arm and compare the
result with the circumference of the other arm. If the arm is swollen, the
nurse should notify the provider who inserted the PICC line. Swelling could
indicate formation of a clot above the site or even catheter rupture.
A nurse is caring for a client who has a central venous catheter and develops
acute shortness of breath. Which of the following actions should the nurse
take first?
A. Clamp the catheter.
B. Position the client in left lateral Trendelenburg.
C. Auscultate breath sounds.
D. Initiate oxygen therapy. - ANSWER A
,Feedback: The greatest risk to this client is injury from further air entering
the central venous catheter; therefore, the first action the nurse should take
is to clamp the catheter.
A nurse is caring for a client who has a central venous catheter and suddenly
develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects
air embolism and clamps the catheter immediately. What other action should
the nurse take at this time?
A. Replace the infusion system.
B. Place the client on his left side in Trendelenburg position.
C. Prepare for chest tube insertion.
D. Remove the catheter. - ANSWER B
Feedback: This position helps trap the air in the apex of the right atrium
rather than allowing it to enter the right ventricle and move to the
pulmonary arterial system.
A nurse is teaching a client who is about to undergo the insertion of a
nontunneled central venous access device. Which of the following statements
should the nurse identify as an indication that the client understands the
instructions?
A. "I will call the clinic if I have persistent hiccups."
B. "I will turn my head in the opposite direction during insertion."
C. "I will have to stay in bed for several hours after the procedure."
D. "I will need to hold my breath when they first put the needle in." -
ANSWER B
Feedback: The client should turn his head away from the insertion site to
, allow optimal accuracy in placing the catheter.
A nurse is caring for client who has a single lumen central venous catheter.
Which of the following actions should the nurse take when accessing the
catheter?
A. Apply firm pressure to the syringe plunger when flushing the lumen.
B. Use clean technique when accessing the catheter.
C. Flush the lumen with sterile water after each use.
D. Use a 10-mL syringe to flush the catheter. - ANSWER D
Feedback: During the flushing procedure, the nurse should use a 10-mL
barrel syringe, because the pressure that is exerted by smaller barrel syringes
increases the risk for rupturing the catheter.
A client has a right subclavian central venous catheter. When reconnecting a
new administration set, which of the following instructions should the nurse
give the client?
A. "Bear down while holding breath."
B. "Turn head to the right."
C. "Sit in semi-Fowler's position."
D. "Exhale slowly." - ANSWER A
Feedback: The client should perform a Valsalva maneuver by holding a breath
and bearing down while the nurse disconnects the old set and reconnects the
new set. This action prevents air from entering the lumen, the heart, and
pulmonary circulation.
A nurse is caring for a client who is receiving a unit of packed red blood cells.
