Which client should the nurse assess first after receiving the hand-off morning report?

Question

Quizplus · Accepted Answer

A peripherally inserted central catheter (PICC) is inserted via the basilic or cephalic veins into the superior vena cava. The nurse should measure and document the external length of the PICC during dressing changes. A change in the length of the external portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider for x-ray evaluation of catheter tip placement. (Option A) After abdominal surgery, placement of a nasogastric tube to decompress the stomach and the absence of bowel sounds for 24-72 hours due to postoperative paralytic ileus would be expected. (Option C) The client with malabsorption syndrome is unable to digest and absorb nutrients by the gastrointestinal tract. Peripheral parenteral nutrition with 10% dextrose is an expected treatment. (Option D) The hemoglobin A1C level of 9% is above the recommended level (ie, <7%) and reflects inadequate glycemic control, which can be expected in a client with diabetes mellitus. Educational objective: A change in the length of the external portion of a peripherally inserted central catheter (PICC) can indicate migration of the catheter from its original position. If migration is suspected, the nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider immediately for evaluation and x-ray verification of placement of the catheter tip.

Which Client Should the Nurse Assess first After Receiving the Hand-Off