The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action?
Numbness and tingling to the left hand.
Slight bloody drainage at the subclavian insertion site.
Dressing is beginning to lift around the insertion site.
Slight redness at the subclavian insertion site.
The Correct Answer is A
A. Numbness and tingling in the left hand could indicate compromised blood flow or nerve damage, potentially due to the arterial line, requiring immediate assessment and intervention.
B. Slight bloody drainage is a common finding and typically does not require immediate action.
C. A dressing beginning to lift should be addressed to maintain a sterile environment but is not an emergency.
D. Slight redness at the insertion site may indicate mild irritation or early signs of infection, but it does not require immediate intervention compared to the potential vascular or nerve compromise suggested by numbness and tingling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Epinephrine is an important drug in resuscitation but is administered after defibrillation in the algorithm.
B. Defibrillation is the priority intervention for ventricular fibrillation, as it is the only treatment that can convert the heart rhythm back to a viable one.
C. Airway management is crucial, but in the context of ventricular fibrillation, defibrillation takes precedence to restore a life-sustaining rhythm.
D. Amiodarone is used in the treatment of refractory ventricular fibrillation, but it is not the immediate priority over defibrillation.
Correct Answer is D
Explanation
A. An electrophysiology study assesses the electrical activity of the heart but does not evaluate heart function or chamber size.
B. A 12-lead electrocardiogram records the electrical activity of the heart but does not provide detailed information on heart function or chamber size.
C. Cardiac catheterization is an invasive procedure used to assess coronary artery disease and other structural heart conditions but is not the primary study for evaluating heart function and chamber size.
D. An echocardiogram is a non-invasive ultrasound that provides detailed images of the heart, including its function, chamber size, and valve function, making it the best choice for this purpose.
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