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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. When a client experiences symptoms of extravasation, such as pain, burning, and swelling, especially with a vesicant medication, the priority is to stop the infusion and remove the catheter immediately to prevent further tissue damage. Removing the catheter promptly helps minimize the amount of medication that may have leaked into the surrounding tissues.
A. Elevating the extremity on a pillow may help reduce swelling and discomfort in some cases, but it is not the first action the nurse should take when a vesicant medication has caused pain, burning, and swelling at the IV site.
C. Keeping the catheter in place is not advisable when extravasation has occurred, especially with a vesicant medication. Continuing the infusion could lead to further tissue damage and exacerbate the client's symptoms. Removing the catheter is necessary to prevent additional medication from entering the surrounding tissues.
D. While applying a cool compress may provide temporary relief from discomfort, it is not the first action the nurse should take when managing extravasation caused by a vesicant medication. The priority is to stop the infusion, remove the catheter, and assess the extent of tissue damage. Cool compresses may be used after the catheter removal to help reduce swelling and discomfort.
Correct Answer is C
Explanation
C. Prioritizing essential information and presenting it first can increase the likelihood that the client grasps key concepts and retains important details. By focusing on the most crucial information initially, the client is more likely to understand and remember the core concepts of the teaching session. This approach helps prevent information overload and ensures that the client receives the most critical information upfront, enhancing their learning outcomes.
A. Extreme temperatures, whether too hot or too cold, can be distracting and uncomfortable for the client, potentially detracting from their ability to focus on the teaching session and retain information.
B. Postponing a teaching session if the client appears to be mildly anxious: This strategy acknowledges the importance of addressing the client's emotional state in facilitating effective learning. If a client appears to be mildly anxious or emotionally distressed, it may be beneficial to postpone the teaching session temporarily until the client feels more calm and receptive to learning. Addressing the client's emotional needs and ensuring a supportive environment can enhance their ability to engage in the teaching process and retain information effectively.
D. While some individuals may find listening to music relaxing or enjoyable, it can also serve as a distraction during a teaching session, especially if the music competes with the nurse's instructions or interferes with the client's ability to concentrate.
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