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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Dehydration is a state of insufficient fluid intake or excessive fluid loss, leading to electrolyte imbalances and increased concentrations of solutes in the blood. The elevated sodium level (hypernatremia) and slightly elevated glucose level in the context of dehydration are consistent with the laboratory findings. Dehydration can also cause elevated BUN due to decreased kidney perfusion and impaired renal function secondary to hypovolemia. Therefore, dehydration is the most likely condition based on the laboratory findings.
A. SIADH is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia (low sodium levels). In this case, the sodium level is elevated, which is not consistent with SIADH. Therefore, SIADH is unlikely.
B. Low-protein diet is not typically associated with the laboratory findings presented. Low protein intake would not directly cause elevated sodium, potassium, glucose, or BUN levels. Therefore, this option is unlikely.
D. Renal failure is characterized by impaired kidney function, resulting in electrolyte imbalances, elevated BUN, and abnormal creatinine levels. However, the creatinine level in this case is within the normal range, suggesting preserved kidney function. Additionally, the elevated sodium level is not typically associated with renal failure. Therefore, renal failure is less likely.
Correct Answer is D
Explanation
D. In metabolic acidosis, the pH would be low (acidemic) and the HCO3 level would be below the normal range. In the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, indicating metabolic acidosis.
A. In respiratory alkalosis, the pH would be elevated (alkalotic) and the PaCO2 would be below the normal range (hypocapnia). However, in the provided ABG results, the pH is low (acidemia) rather than high, ruling out respiratory alkalosis.
B. In respiratory acidosis, the pH would be low (acidemic) and the PaCO2 would be above the normal range (hypercapnia). However, in the provided ABG results, the PaCO2 is within the normal range, ruling out respiratory acidosis.
C. In metabolic alkalosis, the pH would be elevated (alkalotic) and the HCO3 level would be above the normal range. However, in the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, ruling out metabolic alkalosis.
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