NU260 WEEK 7 FINAL REVIEW |\ |\ |\ |\ |\
questions with answers |\ |\
A nurse is caring for a client who has just had a central venous
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
access line inserted. What
|\ |\ |\
action will the nurse take next?
|\ |\ |\ |\ |\
a. Begin the prescribed infusion via the new access.
|\ |\ |\ |\ |\ |\ |\ |\
b. Ensure that an x-ray is completed to confirm placement.
|\ |\ |\ |\ |\ |\ |\ |\ |\
c. Check medication calculations with a second RN.
|\ |\ |\ |\ |\ |\ |\
d. Make sure that the solution is appropriate for a central line. -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔ANS: B |\ |\ |\
A central venous access device, once placed, needs an x-ray
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
confirmation of proper placement |\ |\ |\
before it is used. The bedside nurse would be responsible for
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
beginning the infusion once |\ |\ |\
placement has been verified. Any IV solution can be given
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
through a central line.
|\ |\ |\
A nurse assesses a client who has a radial artery catheter. Which
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment will the nurse |\ |\ |\
complete first? |\
a. Amount of pressure in fluid container
|\ |\ |\ |\ |\ |\
b. Date of catheter tubing change
|\ |\ |\ |\ |\
c. Type of dressing over the site
|\ |\ |\ |\ |\ |\
d. Skin color and capillary refill - CORRECT ANSWERS ✔✔ANS: D
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
,An intra-arterial catheter may cause arterial occlusion, which can
|\ |\ |\ |\ |\ |\ |\ |\
lead to absent or decreased
|\ |\ |\ |\ |\
perfusion to the extremity. Assessment of color, warmth, |\ |\ |\ |\ |\ |\ |\ |\
sensation, capillary refill time, and |\ |\ |\ |\
distal pulses (if appropriate) are assessments for circulation distal
|\ |\ |\ |\ |\ |\ |\ |\
to the catheter site. The
|\ |\ |\ |\ |\
nurse would note that there is enough pressure in the fluid
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
container to keep the system |\ |\ |\ |\
flushed, and would check to see whether the catheter tubing
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
needs to be changed. However, |\ |\ |\ |\
these are not assessments of greatest concern. The type of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
dressing over the site would be |\ |\ |\ |\ |\
noted and most likely prescribed by policy.
|\ |\ |\ |\ |\ |\
A nurse teaches a client who is being discharged home with a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
peripherally inserted central |\ |\
catheter (PICC). Which statement will 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." - CORRECT ANSWERS ✔✔ANS: A |\ |\ |\ |\ |\ |\ |\ |\
A properly placed PICC (in the antecubital fossa or the basilic
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
vein) allows the client
|\ |\ |\
,considerable freedom of movement. Clients can participate in |\ |\ |\ |\ |\ |\ |\ |\
most activities of daily living;
|\ |\ |\ |\
however, heavy lifting can dislodge the catheter or occlude the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
lumen. Although it is |\ |\ |\
important to keep the insertion site and tubing dry, the client can
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
shower. The device is
|\ |\ |\ |\
flushed with heparin. |\ |\
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 0-10 - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
✔✔ANS: B |\
Complications of epidural therapy include infection, bleeding, |\ |\ |\ |\ |\ |\ |\
leakage of cerebrospinal fluid, |\ |\ |\
occlusion of the catheter lumen, and catheter migration.
|\ |\ |\ |\ |\ |\ |\ |\
Headache, neck stiffness, and a |\ |\ |\ |\
temperature higher than 101° F (37.8° C) are signs of meningitis |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
and would be reported to the
|\ |\ |\ |\ |\
primary health care provider immediately. The other findings are
|\ |\ |\ |\ |\ |\ |\ |\ |\
important but do not require |\ |\ |\ |\
immediate intervention. |\
, A nurse assesses a client who had an intraosseous catheter
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
placed in the left leg. Which
|\ |\ |\ |\ |\
assessment finding is of greatest concern? |\ |\ |\ |\ |\
a. The catheter has been in place for 20 hours.
|\ |\ |\ |\ |\ |\ |\ |\ |\
b. The client has poor vascular access in the upper extremities.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
c. The catheter is placed in the proximal tibia.
|\ |\ |\ |\ |\ |\ |\ |\
d. The client's left lower extremity is cool to the touch. -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔ANS: D |\ |\ |\
Compartment syndrome is a condition in which increased tissue |\ |\ |\ |\ |\ |\ |\ |\ |\
pressure in a confined |\ |\ |\
anatomic space causes decreased blood flow to the area. A cool
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
extremity can signal the |\ |\ |\
possibility of this syndrome. All other findings are important;
|\ |\ |\ |\ |\ |\ |\ |\ |\
however, the possible |\ |\
development of compartment syndrome requires immediate |\ |\ |\ |\ |\ |\
intervention because the client |\ |\ |\
could require amputation of the limb if the nurse does not
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
correctly assess and respond to this
|\ |\ |\ |\ |\
perfusion problem. |\
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.
|\ |\ |\ |\ |\ |\ |\
questions with answers |\ |\
A nurse is caring for a client who has just had a central venous
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
access line inserted. What
|\ |\ |\
action will the nurse take next?
|\ |\ |\ |\ |\
a. Begin the prescribed infusion via the new access.
|\ |\ |\ |\ |\ |\ |\ |\
b. Ensure that an x-ray is completed to confirm placement.
|\ |\ |\ |\ |\ |\ |\ |\ |\
c. Check medication calculations with a second RN.
|\ |\ |\ |\ |\ |\ |\
d. Make sure that the solution is appropriate for a central line. -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔ANS: B |\ |\ |\
A central venous access device, once placed, needs an x-ray
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
confirmation of proper placement |\ |\ |\
before it is used. The bedside nurse would be responsible for
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
beginning the infusion once |\ |\ |\
placement has been verified. Any IV solution can be given
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
through a central line.
|\ |\ |\
A nurse assesses a client who has a radial artery catheter. Which
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment will the nurse |\ |\ |\
complete first? |\
a. Amount of pressure in fluid container
|\ |\ |\ |\ |\ |\
b. Date of catheter tubing change
|\ |\ |\ |\ |\
c. Type of dressing over the site
|\ |\ |\ |\ |\ |\
d. Skin color and capillary refill - CORRECT ANSWERS ✔✔ANS: D
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
,An intra-arterial catheter may cause arterial occlusion, which can
|\ |\ |\ |\ |\ |\ |\ |\
lead to absent or decreased
|\ |\ |\ |\ |\
perfusion to the extremity. Assessment of color, warmth, |\ |\ |\ |\ |\ |\ |\ |\
sensation, capillary refill time, and |\ |\ |\ |\
distal pulses (if appropriate) are assessments for circulation distal
|\ |\ |\ |\ |\ |\ |\ |\
to the catheter site. The
|\ |\ |\ |\ |\
nurse would note that there is enough pressure in the fluid
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
container to keep the system |\ |\ |\ |\
flushed, and would check to see whether the catheter tubing
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
needs to be changed. However, |\ |\ |\ |\
these are not assessments of greatest concern. The type of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
dressing over the site would be |\ |\ |\ |\ |\
noted and most likely prescribed by policy.
|\ |\ |\ |\ |\ |\
A nurse teaches a client who is being discharged home with a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
peripherally inserted central |\ |\
catheter (PICC). Which statement will 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." - CORRECT ANSWERS ✔✔ANS: A |\ |\ |\ |\ |\ |\ |\ |\
A properly placed PICC (in the antecubital fossa or the basilic
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
vein) allows the client
|\ |\ |\
,considerable freedom of movement. Clients can participate in |\ |\ |\ |\ |\ |\ |\ |\
most activities of daily living;
|\ |\ |\ |\
however, heavy lifting can dislodge the catheter or occlude the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
lumen. Although it is |\ |\ |\
important to keep the insertion site and tubing dry, the client can
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
shower. The device is
|\ |\ |\ |\
flushed with heparin. |\ |\
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 0-10 - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
✔✔ANS: B |\
Complications of epidural therapy include infection, bleeding, |\ |\ |\ |\ |\ |\ |\
leakage of cerebrospinal fluid, |\ |\ |\
occlusion of the catheter lumen, and catheter migration.
|\ |\ |\ |\ |\ |\ |\ |\
Headache, neck stiffness, and a |\ |\ |\ |\
temperature higher than 101° F (37.8° C) are signs of meningitis |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
and would be reported to the
|\ |\ |\ |\ |\
primary health care provider immediately. The other findings are
|\ |\ |\ |\ |\ |\ |\ |\ |\
important but do not require |\ |\ |\ |\
immediate intervention. |\
, A nurse assesses a client who had an intraosseous catheter
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
placed in the left leg. Which
|\ |\ |\ |\ |\
assessment finding is of greatest concern? |\ |\ |\ |\ |\
a. The catheter has been in place for 20 hours.
|\ |\ |\ |\ |\ |\ |\ |\ |\
b. The client has poor vascular access in the upper extremities.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
c. The catheter is placed in the proximal tibia.
|\ |\ |\ |\ |\ |\ |\ |\
d. The client's left lower extremity is cool to the touch. -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔ANS: D |\ |\ |\
Compartment syndrome is a condition in which increased tissue |\ |\ |\ |\ |\ |\ |\ |\ |\
pressure in a confined |\ |\ |\
anatomic space causes decreased blood flow to the area. A cool
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
extremity can signal the |\ |\ |\
possibility of this syndrome. All other findings are important;
|\ |\ |\ |\ |\ |\ |\ |\ |\
however, the possible |\ |\
development of compartment syndrome requires immediate |\ |\ |\ |\ |\ |\
intervention because the client |\ |\ |\
could require amputation of the limb if the nurse does not
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
correctly assess and respond to this
|\ |\ |\ |\ |\
perfusion problem. |\
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.
|\ |\ |\ |\ |\ |\ |\
