A nurse is teaching a client who has bradycardia about how to prevent vagal stimulation. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A. Use a 3 mL syringe to flush the catheter: Small syringes (3 mL) create high pressure that can damage the lumen of a peripherally inserted central catheter (PICC). Larger syringes, typically 10 mL or greater, are recommended to safely flush and maintain catheter integrity.

B. Cleanse the port with povidone-iodine prior to obtaining the specimen: Current guidelines recommend using an alcohol-based antiseptic (e.g., 70% isopropyl alcohol) rather than povidone-iodine for cleaning catheter hubs due to faster action and reduced contamination risk.

C. Flush with 20 mL of 0.9% sodium chloride after obtaining the blood sample: While flushing is required, the volume depends on the protocol and whether blood was drawn for lab testing. Immediate flushing with 10 mL is often sufficient; 20 mL may be excessive unless the protocol specifies.

D. Instruct the client to perform the Valsalva maneuver during the blood draw: Performing the Valsalva maneuver increases intrathoracic pressure and reduces the risk of air embolism when accessing a central line. This is a recommended safety measure during blood draws from PICC lines.

Rationale for correct choices

• Sudden onset of dyspnea and chest discomfort: These symptoms may indicate acute cardiopulmonary compromise such as pulmonary embolism, acute heart failure, or infection. Sudden dyspnea in a post-op orthopedic client requires immediate assessment and intervention to prevent deterioration.

• Tachypnea and appearance of distress: Rapid, labored breathing indicates the client is struggling to maintain adequate oxygenation and may signal hypoxemia or respiratory failure. Immediate follow-up is necessary to prevent further compromise.

• Crackles heard in bilateral lungs: Bilateral crackles suggest fluid accumulation in the alveoli, possibly from pulmonary edema or early pneumonia. This finding correlates with respiratory distress and requires prompt evaluation.

• S3 and S4 heart sounds noted: Extra heart sounds can indicate left ventricular dysfunction or volume overload, suggesting acute heart failure. Timely assessment is critical to prevent worsening cardiac output and pulmonary congestion.

• Temperature 38.9° C (102° F): Fever indicates possible infection, which in a post-operative patient could suggest pneumonia, surgical site infection, or sepsis. Early recognition and treatment are essential.

• Heart rate 112/min: Tachycardia may be a compensatory response to hypoxia, fever, or fluid overload. Persistent elevation increases cardiac workload and risk of decompensation.

• Respiratory rate 34/min: A significantly elevated respiratory rate confirms respiratory distress and inadequate oxygenation, warranting immediate intervention such as supplemental oxygen adjustment or further diagnostics.

Rationale for incorrect choices

• Client is awake and oriented x4: The client’s alertness and orientation indicate that cerebral perfusion and cognitive function are intact at this time. While this is important to note, it does not indicate acute cardiopulmonary compromise or a life-threatening event, so it does not require immediate follow-up.

• Surgical site is dressed, dry, and intact: The dressing being clean, dry, and intact indicates there is currently no active bleeding or wound complication. While ongoing monitoring is important post-operatively, this finding does not necessitate urgent intervention compared with the client’s acute respiratory and cardiovascular symptoms.