Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is completing discharge teaching with a client who has a peripherally inserted central catheter (PICC) line in the left arm.
Which of the following instructions should the nurse include in the teaching?
A. Clean the insertion site using 20 mL of hydrogen peroxide.
Choice A, Clean the insertion site using 20 mL of hydrogen peroxide, is not the correct answer because hydrogen peroxide should not be used to clean the insertion site of a PICC line.
B. Change the catheter dressing daily.
Choice B, Changing the catheter dressing daily, is not the correct answer because the catheter dressing should be changed every 3 to 7 days or as directed by a healthcare provider.
C. Use a 10-mL syringe to flush the line.
A 10-mL syringe is the minimum size that should be used to flush a PICC line to prevent damage to the catheter.
D. Do not elevate the arm above the level of the heart.
Choice D, Do not elevate the arm above the level of the heart, is not the correct answer because there is no restriction on elevating the arm above the level of the heart with a PICC line.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
A 10-mL syringe is the minimum size that should be used to flush a PICC line to prevent damage to the catheter.
Choice A, Clean the insertion site using 20 mL of hydrogen peroxide, is not the correct answer because hydrogen peroxide should not be used to clean the insertion site of a PICC line.
Choice B, Changing the catheter dressing daily, is not the correct answer because the catheter dressing should be changed every 3 to 7 days or as directed by a healthcare provider.
Choice D, Do not elevate the arm above the level of the heart, is not the correct answer because there is no restriction on elevating the arm above the level of the heart with a PICC line.
Similar Questions
A nurse is monitoring a client's heart rhythm following the insertion of a permanent pacemaker.
Which of the following images should the nurse expect?
A. A regular sinus rhythm.
Choice A, A regular sinus rhythm, is not the correct answer because a regular sinus rhythm is a normal heart rhythm that originates from the sinoatrial (SA) node and does not involve a pacemaker.
B. A chaotic, irregular rhythm.
Choice B, A chaotic, irregular rhythm, is not the correct answer because a pacemaker is designed to regulate the heartbeat and prevent chaotic or irregular rhythms.
C. Absence of any electrical activity.
Choice C, the Absence of any electrical activity, is not the correct answer because a pacemaker sends electrical signals to the heart to regulate its activity.
D. A series of spikes followed by a QRS complex.
A pacemaker sends electrical signals to the heart to regulate the heartbeat. On an electrocardiogram (ECG), these signals appear as small spikes followed by a QRS complex, which represents the contraction of the ventricles.
Full Explanation
A pacemaker sends electrical signals to the heart to regulate the heartbeat.
On an electrocardiogram (ECG), these signals appear as small spikes followed by a QRS complex, which represents the contraction of the ventricles.
Choice A, A regular sinus rhythm, is not the correct answer because a regular sinus rhythm is a normal heart rhythm that originates from the sinoatrial (SA) node and does not involve a pacemaker.
Choice B, A chaotic, irregular rhythm, is not the correct answer because a pacemaker is designed to regulate the heartbeat and prevent chaotic or irregular rhythms.
Choice C, the Absence of any electrical activity, is not the correct answer because a pacemaker sends electrical signals to the heart to regulate its activity.
A nurse is teaching a client who has endometriosis about the adverse effects of leuprolide.
Which of the following manifestations should the nurse include in the teaching?
A. Pallor.
Choice A, Pallor, is not the correct answer because pallor (pale skin) is not a common side effect of leuprolide.
B. Increased appetite.
Choice B, Increased appetite, is not the correct answer because increased appetite is not a common side effect of leuprolide.
C. Bone loss.
Leuprolide can cause bone loss, which can lead to osteoporosis and an increased risk of bone fractures.
D. Hypoglycemia.
Choice D, Hypoglycemia, is not the correct answer because hypoglycemia (low blood sugar) is not a common side effect of leuprolide.
Full Explanation
Leuprolide can cause bone loss, which can lead to osteoporosis and an increased risk of bone fractures.
Choice A, Pallor, is not the correct answer because pallor (pale skin) is not a common side effect of leuprolide.
Choice B, Increased appetite, is not the correct answer because increased appetite is not a common side effect of leuprolide.
Choice D, Hypoglycemia, is not the correct answer because hypoglycemia (low blood sugar) is not a common side effect of leuprolide.
A nurse is monitoring a client who is receiving 2 units of packed RBCs.
Which of the following manifestations indicates a hemolytic transfusion reaction?
A. Back pain.
Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
B. Bradycardia.
Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
C. Hypertension.
Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
D. Chills.
Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
Full Explanation
The correct answer is A. Back pain.
Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
