A client has just undergone a bedside central venous catheter insertion using ultrasound guidance. The nurse knows to check which diagnostic result before initiating the client's prescribed intravenous solution flow rate at 100 mL/hr?

Chest x-ray results

Serum osmolality

Intake and output record

Serum glucose level

Answer and Explanation

The Correct Answer is A

A. Chest x-ray results: This is the correct choice. After central venous catheter insertion, a chest x-ray is crucial to confirm correct catheter placement and to rule out complications such as pneumothorax or catheter malposition.
B. Serum osmolality: While serum osmolality can provide information about fluid and electrolyte balance, it is not directly related to verifying catheter placement or the immediate post-insertion assessment.
C. Intake and output record: Although important for monitoring fluid balance, the intake and output record does not confirm the proper placement of the central venous catheter.
D. Serum glucose level: This is not relevant to verifying the catheter placement or ensuring proper functioning immediately after insertion.

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Correct Answer is A

Explanation

A. Discontinue the intravenous line: The presence of tenderness and a red streak suggests phlebitis or possibly an early sign of infection. The first and most important step is to discontinue the IV line to prevent further irritation or infection.
B. Complete an incident report: While documentation is important, it is not the first action to take. Immediate attention should be given to the client’s physical condition before completing any paperwork.
C. Start a new IV in the right hand: While starting a new IV is necessary for continued therapy, the first action should be to remove the current IV line to prevent further complications. Starting a new IV can be done immediately afterward.
D. Place a warm compress over the site: A warm compress can help alleviate pain and reduce inflammation, but the priority action is to discontinue the IV line to stop further damage or infection.

A. Administer 10% sodium chloride via rapid infusion B. Administer intranasal antidiuretic hormone C. Encourage oral fluid intake D. Place the client on seizure precautions

Correct Answer is D

Explanation

A. Administer 10% sodium chloride via rapid infusion: Rapid infusion of high concentrations of sodium chloride can be dangerous and is not the standard treatment for severe hyponatremia.
B. Administer intranasal antidiuretic hormone: This would not be appropriate for correcting severe hyponatremia and could potentially worsen the condition.
C. Encourage oral fluid intake: For severe hyponatremia, oral fluid intake might not be sufficient and could exacerbate the condition if there is fluid overload.
D. Place the client on seizure precautions: This is the correct choice. Severe hyponatremia (sodium < 120 mEq/L) can lead to neurological symptoms and seizures, so implementing seizure precautions is crucial for safety.

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A client has just undergone a bedside central venous catheter insertion using ultrasound guidance. The nurse knows to check which diagnostic result before initiating the client's prescribed intravenous solution flow rate at 100 mL/hr?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has received IV solution for three (3) days through a 20-gauge IV catheter placed in the left hand. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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