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

Answer and Explanation

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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Correct Answer is D

Explanation

D. Experiencing multiple stressors simultaneously can overwhelm an individual's coping resources and make it more difficult to effectively manage stress. Coping with multiple stressors can lead to feelings of being overwhelmed, heightened anxiety, and decreased ability to cope with each stressor individually.
A. Undergoing a biopsy can be a stressful experience due to uncertainty about the results and fear of the procedure itself. However, the level of difficulty in coping with this stressor can vary among individuals depending on factors such as their coping mechanisms, social support, and previous experiences with medical procedures.
B. Relocating to an assisted-living facility can be a significant life transition, involving changes in living arrangements, loss of independence, and adjustment to a new environment. This stressor can be particularly challenging for individuals who have strong attachments to their current living situation or who are facing health-related issues that necessitate the move.
C. Understanding and researching the stressor can sometimes help individuals cope better by providing knowledge and a sense of control. However, this does not necessarily make coping with the stressor easier, especially if the stressor itself is significant or if the individual lacks adequate support or resources to manage it effectively.

A. On left side, with the knees bent B. With the head of the bed elevated 30-45 degrees C. On the right side, with a pillow behind the back D. With the head of the bed elevated 15 degree

Correct Answer is B

Explanation

B. Elevating the head of the bed to 30-45 degrees is the recommended position for administering enteral feeding to reduce the risk of aspiration. This semi-upright position helps promote gastric emptying and reduces the likelihood of reflux or regurgitation of the feed into the lungs. It also allows for better tolerance of the feeding and minimizes the risk of complications.
A. Positioning the client on the left side with the knees bent is not typically recommended for enteral feeding. This position may increase the risk of aspiration, especially if the client has impaired swallowing or if there are issues with gastric emptying. It may also not be the most comfortable or practical position for administering enteral feeding.
C. Positioning the client on the right side with a pillow behind the back is not a standard practice for administering enteral feeding. This position may not provide optimal access for administering the feed, and it does not offer the benefits of head elevation to reduce the risk of aspiration.

D. Elevating the head of the bed to only 15 degrees may not provide sufficient upright positioning to reduce the risk of aspiration during enteral feeding. While it is better than lying completely flat, a higher degree of elevation (30-45 degrees) is generally recommended for optimal safety and effectiveness of enteral feeding.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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