A Nurse is Caring for a Client Who is Receiving Total Parenteral Nutrition

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? Measure the circumference of both upper arms. Correct! Notify the provider who inserted the PICC line. Remove the PICC line. Apply a cold pack to the client's upper arm. 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 and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which the following tasks should the nurse delegate to the LPN? (Select all that apply.) Provide discharge instructions to a confused client's spouse. Provide discharge instructions to a confused client's spouse. Obtain vital signs from a client who is 6 hour postoperative. Correct! Administer a tap-water enema to a client who is preoperative. Correct! Initiate a plan of care for a client who is postoperative from an appendectomy. Catheterize a client who has not voided in 8 hr. Correct! Obtain vital signs from a client who is 6 hour postoperative. is correct: Correct. Obtaining is a task that is appropriate to the education and skills of an LPN. Administer a tap-water enema to a client who is preoperative. is correct: Correct. Administering a tap-water enema is a task that is appropriate to the education and skills of an LPN. Catheterize a client who has not voided in 8 hr. is correct: Correct. Urinary catheterization is a task that is appropriate to the education and skills of an LPN. A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? "I need to talk to you about unit expectations regarding delegating and completing tasks." Correct! "Several staff members have commented that you don't do your fair share of the work." "If you don't do your share of the work, I will have to inform the nurse manager." "You have been very inconsiderate of others by not completing your share of the work." Correct. This statement opens the conversation in a nonthreatening way. The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual. A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? Perform a neurovascular assessment. Correct! Explain the discharge instructions to the client and parents. Provide reassurance to the client and parents. Apply an ice pack to the casted leg. The greatest risk to the client is neurovascular injury. Therefore, the priority action is to perform a neurovascular assessment. This consists of assessing the involved extremity (the lower leg) at the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check." A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? Observe client’s respiratory status. Elevate the head of the client's bed 30° to 45°.Correct! Monitor intake and output every 8 hr. Check residual volume every 4 to 6 hr. A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote gastric emptying and reduce the risk of aspiration.