A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?- Nurselytic

Question 1 of 5

A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

A. Inspect the PICC insertion site for signs of infection. B. Observe the antecubital fossa for inflammation. C. Auscultate lung sounds for signs of respiratory distress. D. Check for signs of phlebitis or thrombosis along the catheter site.

Correct Answer: B

Rationale: Observing the antecubital fossa for inflammation can indicate infection or complications related to the PICC line, which is critical to assess in clients with a fever.

Question 2 of 5

A client is receiving morphine for postoperative pain. What is the nurse's priority assessment?

A. Monitor the client's respiratory rate. B. Monitor the client's level of consciousness. C. Assess the client's level of pain. D. Monitor the client's blood pressure.

Correct Answer: A

Rationale: Monitoring respiratory rate helps assess for respiratory depression, a common side effect of morphine.

Question 3 of 5

A client with a colostomy is being discharged. What teaching is most important for the nurse to provide?

A. Change the ostomy bag daily to prevent skin irritation. B. Avoid foods that can cause gas, such as broccoli. C. Empty the ostomy pouch when it is one-third full. D. Use a skin barrier to protect the surrounding skin.

Correct Answer: C

Rationale: Emptying the ostomy pouch when it's one-third full prevents leakage and skin irritation.

Question 4 of 5

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the UAP who is working with the nurse?

A. Encourage the client to increase fluid intake B. Document the absence of reaction C. Notify the nurse if the client develops a fever D. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete

Correct Answer: D

Rationale: Monitoring vital signs throughout a transfusion is critical, as reactions can occur later in the process. The UAP should continue to check vital signs regularly to ensure that any delayed reaction is promptly detected.

Question 5 of 5

A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?

A. Immunizations can trigger a relapse of the disease, so get plenty of extra rest B. Visual problems are unrelated to the recent immunizations C. Increase fluid intake to reduce symptoms of fatigue D. Consult the healthcare provider immediately for steroid therapy

Correct Answer: A

Rationale: Immunizations can sometimes trigger relapses in multiple sclerosis due to the activation of the immune system. Extra rest can help manage these symptoms. While increased fluid intake may be helpful, the nurse should focus on explaining the connection between immunizations and MS symptoms.

Nurselytic

HESI RN

HESI RN

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