Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. Apply a cold pack to the client's upper arm.
Applying a cold pack to the client’s upper arm would not be the first action to take. It may help reduce swelling, but it does not address the underlying issue.
B. Measure the circumference of both upper arms.
Measuring the circumference of both upper arms is the correct first action. This will provide objective data about the extent of the swelling, which can then be reported to the healthcare provider.
C. Remove the PICC line.
Removing the PICC line is not the first action to take. This should only be done under the direction of a healthcare provider.
D. Notify the provider who inserted the PICC line.
Notifying the provider who inserted the PICC line is important, but it should be done after gathering all necessary data, including measuring the arm circumference.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Med Surg Custom Proctored Exam 2. Take the full exam now
Full Explanation
Choice A rationale:
Applying a cold pack to the client’s upper arm would not be the first action to take. It may help reduce swelling, but it does not address the underlying issue.
Choice B rationale:
Measuring the circumference of both upper arms is the correct first action. This will provide objective data about the extent of the swelling, which can then be reported to the healthcare provider.
Choice C rationale:
Removing the PICC line is not the first action to take. This should only be done under the direction of a healthcare provider.
Choice D rationale:
Notifying the provider who inserted the PICC line is important, but it should be done after gathering all necessary data, including measuring the arm circumference.
Similar Questions
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
A. Localized edema.
Localized edema is a common sign of infection. The body sends extra fluid to the area as part of the inflammatory response.
B. An increase in neutrophils.
An increase in neutrophils, a type of white blood cell, is a common response to infection. Neutrophils are part of the body’s immune response and work to fight off invading bacteria.
C. An increase in platelets.
An increase in platelets is not typically associated with infection. Platelets are involved in blood clotting, not the immune response.
D. Bradycardia.
Bradycardia, or a slow heart rate, is not typically associated with infection. Infection usually causes an increased heart rate, not a decreased one.
E. An increase in RBCS.
An increase in RBCs is not typically associated with infection. RBCs carry oxygen around the body, but their number does not usually change in response to infection.
Full Explanation
Choice A rationale:
Localized edema is a common sign of infection. The body sends extra fluid to the area as part of the inflammatory response.
Choice B rationale:
An increase in neutrophils, a type of white blood cell, is a common response to infection. Neutrophils are part of the body’s immune response and work to fight off invading bacteria.
Choice C rationale:
An increase in platelets is not typically associated with infection. Platelets are involved in blood clotting, not the immune response.
Choice D rationale:
Bradycardia, or a slow heart rate, is not typically associated with infection. Infection usually causes an increased heart rate, not a decreased one.
Choice E rationale:
An increase in RBCs is not typically associated with infection. RBCs carry oxygen around the body, but their number does not usually change in response to infection.
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F).
Which of the following actions should the nurse perform?
A. Complete a neurological check.
Completing a neurological check is the correct action. The client’s sudden confusion and drowsiness could indicate a neurological issue, such as a stroke.
B. Increase the client's fluid intake.
Increasing the client’s fluid intake is not the first action to take. While dehydration can cause confusion, other causes need to be ruled out first.
C. Administer the prescribed PRN antihypertensive medication.
Administering the prescribed PRN antihypertensive medication is not the first action to take. The client’s blood pressure is not elevated, so this medication is not needed at this time.
D. Hold the client's evening dose of digoxin.
Holding the client’s evening dose of digoxin is not the first action to take. The client’s symptoms are not necessarily related to this medication.
Full Explanation
Choice A rationale:
Completing a neurological check is the correct action. The client’s sudden confusion and drowsiness could indicate a neurological issue, such as a stroke.
Choice B rationale:
Increasing the client’s fluid intake is not the first action to take. While dehydration can cause confusion, other causes need to be ruled out first.
Choice C rationale:
Administering the prescribed PRN antihypertensive medication is not the first action to take. The client’s blood pressure is not elevated, so this medication is not needed at this time.
Choice D rationale:
Holding the client’s evening dose of digoxin is not the first action to take. The client’s symptoms are not necessarily related to this medication.
A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf.
The nurse anticipates which of the following orders when notifying the provider of this finding?
A. Obtain impedance plethysmography.
Impedance plethysmography is a test that uses electrical signals to measure blood flow and can be used to detect deep vein thrombosis (DVT). However, it is not the first-line diagnostic tool for DVT.
B. Apply cold therapy to the affected leg.
Cold therapy can help reduce inflammation and pain, but it is not a diagnostic measure for DVT.
C. Obtain a venous duplex ultrasound.
Venous duplex ultrasound is the most common test used to diagnose DVT. It uses sound waves to create pictures of the blood flowing through the veins in the leg.
D. Monitor Homan's sign.
Homan’s sign is a physical examination finding that was traditionally used to diagnose DVT, but it is not reliable or specific.
Full Explanation
Choice A rationale:
Impedance plethysmography is a test that uses electrical signals to measure blood flow and can be used to detect deep vein thrombosis (DVT). However, it is not the first-line diagnostic tool for DVT.
Choice B rationale:
Cold therapy can help reduce inflammation and pain, but it is not a diagnostic measure for DVT.
Choice C rationale:
Venous duplex ultrasound is the most common test used to diagnose DVT. It uses sound waves to create pictures of the blood flowing through the veins in the leg.
Choice D rationale:
Homan’s sign is a physical examination finding that was traditionally used to diagnose DVT, but it is not reliable or specific.