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. While a CVP catheter might be in place for an extended period, its purpose is not directly related to heart healing.
B. The CVP catheter is used to monitor central venous pressure, which helps guide fluid management and assess right heart function.
C. The CVP catheter does not extend into the left ventricle; it is typically positioned in the superior vena cava or right atrium.
D. The CVP catheter may have multiple lumens for administering fluids, but its primary purpose is hemodynamic monitoring, not just providing IV access.
Correct Answer is A
Explanation
A. Sudden weight gain can indicate fluid retention, a common early sign of heart failure exacerbation. Prompt reporting allows for early intervention.
B. Nitroglycerin is used to treat chest pain, not specifically to prevent heart failure exacerbations.
C. Assessment of the apical pulse is important, but monitoring weight is more directly related to managing heart failure.
D. Compliance with diuretic therapy is important, but recognizing early signs of fluid retention, such as rapid weight gain, is crucial for preventing exacerbations.
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