The nurse is caring for a client who just had a subclavian central venous catheter inserted. Which symptom should the nurse recognize as setting a priority for this client's care?
Decreased pedal pulses
Tachycardia
Presence of bibasilar crackles
Headache
The Correct Answer is B
B. Tachycardia (elevated heart rate) can be a sign of various underlying conditions, including pain, anxiety, or cardiovascular compromise. While tachycardia may occur as a response to stress or pain associated with the catheter insertion procedure, it can also indicate complications such as hemorrhage, cardiac dysrhythmias, or pulmonary embolism, which require prompt evaluation and intervention.
A. While this can be concerning, it is not typically directly related to complications of a subclavian central venous catheter insertion unless there is evidence of arterial injury or thrombosis.
C. Bibasilar crackles are abnormal lung sounds that can indicate fluid accumulation in the lungs, such as pulmonary edema or pneumonia. However, this may not be directly related to the subclavian central venous catheter insertion itself.
D. Headache is a non-specific symptom that can have numerous causes, including stress, dehydration, or tension.
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Related Questions
Correct Answer is C
Explanation
C. Excessive noise in the hospital environment, including alarms, conversations, and equipment noises, can disrupt sleep and negatively impact sleep quality. Therefore, limiting unnecessary noise on the unit is a crucial nursing intervention for improving sleep quality in the acute care setting. This may involve implementing quiet hours, reducing unnecessary conversations and activities during nighttime hours, and using noise-reducing strategies such as earplugs or white noise machines.
A. While providing a bedtime snack may help alleviate hunger and promote comfort, especially if the client is on a restricted diet or experiencing appetite changes, it may not directly address factors affecting sleep quality. Additionally, consuming food close to bedtime may not be suitable for all patients, especially those with dietary restrictions or certain medical conditions. Therefore, while a bedtime snack may be beneficial in some cases, it may not be the most important intervention for improving sleep quality in the acute care setting.
B. Pulling curtains around the bed can help create a sense of privacy and reduce visual distractions, which may contribute to a more conducive sleep environment. Enhanced privacy can also promote relaxation and feelings of security, potentially improving sleep quality. However, while privacy curtains can mitigate some external disturbances, they may not completely eliminate factors that affect sleep, such as noise or light.
D. Providing a backrub can promote relaxation, relieve tension, and enhance comfort, which may contribute to improved sleep quality for some patients. Massage therapy has been shown to reduce stress and promote relaxation, potentially facilitating better sleep. However, while backrubs can be a beneficial adjunct to promoting relaxation and comfort, they may not address all factors that affect sleep quality in the acute care setting.
Correct Answer is D
Explanation
D. Denial is often the initial stage of the grieving process, characterized by disbelief or avoidance of the reality of the situation. Clients may refuse to accept the diagnosis or its implications, clinging to the hope that it is not true. The client's statement of "This cannot be happening to me" is consistent with denial, as they are expressing disbelief or resistance to the reality of their diagnosis.
A. This stage involves feelings of sadness, despair, and hopelessness. While depression is a common response to a terminal diagnosis, the client's statement of "This cannot be happening to me" suggests that they may still be in an earlier stage of grief.
B. Anger is another common stage of the grieving process, characterized by feelings of frustration, resentment, and hostility. Clients may direct their anger towards themselves, others, or even a higher power. While anger can be a prominent reaction to a terminal diagnosis, the client's statement does not explicitly express anger but rather disbelief or resistance.
C. Bargaining is a stage in which individuals may attempt to negotiate or make deals in an effort to change or postpone the inevitable outcome. For example, a client may pray for more time or promise to change their behavior in exchange for a better outcome. The client's statement of "This cannot be happening to me" does not reflect bargaining but rather denial or disbelief.

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