A nurse is caring for a client who has just had a central venous catheter placed via the right subclavian vein. Which of the following actions should the nurse take?

Place the client in the Trendelenburg position

Encourage active range of motion exercises of the right arm

Keep the client's right arm immobilized

Instruct the client to cough frequently

Answer and Explanation

The Correct Answer is C

The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.

Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.

Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.

Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.

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Correct Answer is B

No explanation

A. Dyspnea B. Fever C. Pruritus D. Bradycardia

Correct Answer is A

Explanation

Fluid overload is a potential complication of blood transfusion, and dyspnea is one of the hallmarks of fluid overload. Other signs and symptoms of fluid overload include a headache, hypertension, jugular vein distention, rapid breathing, and tachycardia.

An explanation for incorrect choices:

B. Fever is generally not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a febrile non-hemolytic transfusion reaction.

C. Pruritus is typically not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as an allergic reaction.

D. Bradycardia is not typically associatedwith fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a hemolytic transfusion reaction.

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A nurse is caring for a client who has just had a central venous catheter placed via the right subclavian vein. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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