A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter (CVC). The provider writes a prescription to initiate an IV infusion of Ringer's lactate at 150 mL per hr. Prior to starting the infusion, which of the following actions should the nurse take?

Apply oxygen at 3 L/min per nasal cannula.

Review the chest x-ray report

Flush the catheter with sterile water.

Obtain a peripheral blood glucose level.

Answer and Explanation

The Correct Answer is B

A. Apply oxygen at 3 L/min per nasal cannula: Oxygen administration is not a routine requirement after CVC insertion unless the client is experiencing respiratory distress or hypoxia. It is not necessary prior to starting an IV infusion.

B. Review the chest x-ray report: After insertion of a subclavian CVC, a chest x-ray is required to confirm correct catheter placement and to rule out complications such as pneumothorax. Reviewing the report ensures it is safe to initiate IV fluids through the catheter.

C. Flush the catheter with sterile water: Central lines should be flushed with saline, not sterile water, to maintain patency. Flushing with water can cause hemolysis and is unsafe.

D. Obtain a peripheral blood glucose level: Blood glucose monitoring is not directly related to CVC insertion or initiation of IV fluids unless specifically indicated by the client’s medical condition. It is not a standard preparatory action for starting an infusion.

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Correct Answer is D

Explanation

A. Decrease in blood pressure: Autonomic dysreflexia is characterized by a sudden increase in blood pressure, not a decrease. Hypotension is more typical of spinal shock, making low blood pressure inconsistent with autonomic dysreflexia.

B. Increase in heart rate: During autonomic dysreflexia, the body often responds with bradycardia rather than tachycardia due to baroreceptor-mediated parasympathetic activation. An elevated heart rate is not a typical sign of this condition.

C. Client report of eye twitching: Eye twitching is not associated with autonomic dysreflexia. This symptom may indicate a neurological or electrolyte issue, but it does not help identify the acute hypertensive crisis characteristic of autonomic dysreflexia.

D. Client report of sudden headache: A sudden, severe headache is a hallmark symptom of autonomic dysreflexia caused by abrupt hypertension. This finding, along with other signs such as flushed skin, nasal congestion, and sweating above the level of injury, indicates the need for immediate intervention to prevent complications such as stroke.

A. Test the glucose level of the client's pulmonary secretions. B. Ask the client to speak after air instillation. C. Auscultate the client's stomach during air instillation. D. Test the pH level of the client's gastric aspirate

Correct Answer is D

Explanation

A. Test the glucose level of the client's pulmonary secretions: Testing glucose in pulmonary secretions is not a reliable method for verifying NG tube placement. Pulmonary secretions may have variable glucose levels and cannot confirm gastric placement, making this method unsafe for ensuring the tube is correctly positioned.

B. Ask the client to speak after air instillation: Having the client speak after air instillation is not a valid or safe method to confirm NG tube placement. Speaking does not provide any reliable indication of whether the tube is in the stomach or lungs and could lead to a false sense of security.

C. Auscultate the client's stomach during air instillation: Listening for a “whoosh” of air over the stomach has been a traditional practice but is unreliable and not recommended as the sole method. Air may also enter the lungs, producing a similar sound and potentially causing harm if feeding is initiated in a malpositioned tube.

D. Test the pH level of the client's gastric aspirate: Measuring the pH of aspirated gastric contents is a safe and effective method to confirm NG tube placement. Gastric fluid typically has a pH of 1–5, whereas respiratory secretions are more alkaline. This provides reliable verification before initiating enteral feeding.

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A nurse is caring for a client who has an acute spinal cord injury. Which of the following findings should the nurse recognize as autonomic dysreflexia?

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Correct Answer is D

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