A nurse is caring for a client who has a central venous catheter and reports hearing a gurgling sound on the side of the catheter insertion. Which of the following complications should the nurse suspect?
Catheter occlusion
Catheter migration
Catheter dislodgment
Catheter rupture
The Correct Answer is B
Choice A - Catheter Occlusion: This occurs when the catheter is blocked, preventing the flow of fluids or medication. It is usually indicated by difficulty in flushing the catheter or a slow drip rate¹. However, it does not typically cause a gurgling sound.
Choice B - (Catheter migration) is correct because when a central venous catheter (CVC) migrates from its original position, the tip can enter a smaller vein or a different location where turbulence occurs. This may cause the client to hear a gurgling or bubbling sound, especially during infusion or with position changes. Migration can happen due to coughing, movement, or changes in pressure, and it doesn’t necessarily involve the catheter being visibly out of place
Choice C - (Catheter dislodgment) is incorrect because dislodgment typically refers to the catheter being partially pulled out of the insertion site. This would be more likely to cause external signs like visible catheter movement or fluid leakage at the insertion site, rather than internal gurgling sounds. Gurgling is more associated with internal changes in catheter position, as seen with migration.
Choice D - Catheter Rupture: This is a break or tear in the catheter. It can cause serious complications, including infection and embolism. However, a gurgling sound is not a typical symptom of a catheter rupture¹.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because extravasation is not related to the lifetime cumulative dose limit of doxorubicin, but to the leakage of the medication from the vein into the surrounding tissue. Extravasation can cause severe tissue damage and necrosis, and should be prevented by using a central venous catheter and monitoring the infusion site.
Choice B reason: This is incorrect because red tinged urine and sweat are not related to the lifetime cumulative dose limit of doxorubicin, but to the normal excretion of the medication from the body. Red tinged urine and sweat are expected side effects of doxorubicin and do not indicate toxicity or harm.
Choice C reason: This is correct because an excess amount of doxorubicin can lead to cardiomyopathy, which is a serious and potentially fatal complication of the medication. Cardiomyopathy is a condition in which the heart muscle becomes weak and unable to pump blood effectively. The risk of cardiomyopathy increases with the cumulative lifetime dose of doxorubicin, which should not exceed 450 to 550 mg/m2.
Choice D reason: This is incorrect because myelosuppression is not related to the lifetime cumulative dose limit of doxorubicin, but to the dose-dependent effect of the medication on the bone marrow. Myelosuppression is a condition in which the production of blood cells is reduced, leading to anemia, leukopenia, and thrombocytopenia. Myelosuppression can be managed by adjusting the dose and frequency of doxorubicin and monitoring the blood counts.
Correct Answer is A
Explanation
Choice A reason: Lidocaine is an antiarrhythmic medication that stabilizes the cardiac membrane and suppresses abnormal electrical impulses in the heart. It is used to treat ventricular dysrhythmias, such as ventricular tachycardia and ventricular fibrillation, which can occur after a cardiac arrest.
Choice B reason: Lidocaine is not primarily used to relieve pain, although it has local anesthetic properties. It is not effective for chest pain caused by myocardial ischemia or infarction.
Choice C reason: Lidocaine does not dissolve blood clots, nor does it prevent their formation. It has no anticoagulant or thrombolytic effects.
Choice D reason: Lidocaine does not slow intestinal motility, nor does it affect the gastrointestinal system. It has no antispasmodic or antidiarrheal effects.
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