The nurse is supervising the student nurse in performing a cap change for a peripherally inserted central catheter (PICC) in a patient who recently sustained a traumatic brain injury. Which action by the student nurse best indicates effective learning?

Asks all nonessential individuals to wait outside of the room during the procedure. The cap change procedure is a sterile one; therefore, all individuals who are not essential to the procedure should be asked to wait outside the room. The patient’s recent head injury makes the Trendelenburg position, which is standard for this procedure, contraindicated. The patient’s head should also not be turned for this same reason. The patient should perform a Valsalva maneuver prior to the cap being removed, if able. Taking a deep breath during cap removal places the patient at risk for air entrainment.

The nurse is supervising the student nurse in performing a cap ch...

Category: Reduction of Risk Potential
Difficulty: 9

Topics: Communication & Documentation Delegation, Prioritization and Leadership Disease Prevention Nursing Interventions Patient Education Routes of Administration Health Care Quality Musculoskeletal Neurology

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