The nurse is monitoring a patient who has a central venous catheter in place for signs of complications. Which of the following are potential complications of central venous catheters? (Select all that apply.)

Pneumothorax.

Air embolism.

Catheter-related bloodstream infection.

Catheter occlusion.

Hematoma formation.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason: Pneumothorax: This is a condition where air accumulates in the pleural space, causing the lung to collapse. It can occur during insertion of a central venous catheter if the needle or catheter punctures the lung or the pleura.

Choice B reason:. Air embolism. This is a condition where air bubbles enter the bloodstream and obstruct blood flow. It can occur during insertion, removal or maintenance of a central venous catheter if air enters the catheter or the vein.

Choice C reason:. Catheter-related bloodstream infection. This is an infection that occurs when microorganisms colonize the catheter or the insertion site and enter the bloodstream. It can cause fever, chills, sepsis and other serious complications. It can be prevented by using strict aseptic technique and following infection control guidelines.

Choice D reason:. Catheter occlusion. This is a condition where the catheter lumen becomes blocked by blood clots, fibrin sheaths, precipitates or kinks. It can impair the infusion or withdrawal of fluids and medications. It can be prevented by flushing the catheter regularly with saline or heparin solutions.

Choice E reason: Hematoma formation. This is a condition where blood accumulates under the skin or in the tissues around the insertion site. It can occur due to bleeding from the punctured vein or artery, or from trauma to the site. It can cause pain, swelling, bruising and infection.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason:

Administer the solution via a central line. This is correct because 3% sodium chloride solution is a hypertonic solution that can cause phlebitis and tissue damage if infused peripherally. A central line can deliver the solution more safely and effectively.

Choice B reason:

Monitor serum sodium levels every 4 hours. This is correct because serum sodium levels can indicate the effectiveness of the therapy and the risk of complications such as hypernatremia or cerebral edema. The normal range of serum sodium is 135 to 145 mEq/L.

Choice C reason:

Titrate the infusion rate according to urine output. This is incorrect because the infusion rate of 3% sodium chloride solution should be titrated according to serum sodium levels, not urine output. Urine output can be affected by other factors such as renal function, fluid intake, and diuretics.

Choice D reason:

Assess for signs of fluid overload. This is correct because 3% sodium chloride solution can cause fluid shifts from the intracellular and interstitial spaces to the intravascular space, leading to fluid overload. Signs of fluid overload include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated central venous pressure (CVP), weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit.

Choice E reason:

Keep an accurate intake and output record. This is correct because intake and output records can help monitor the fluid balance and identify any excesses or deficits. Intake includes oral fluids, intravenous fluids, tube feedings, and blood products. Output includes urine, stool, vomitus, drainage, and insensible losses.

A. Jugular vein distension. B. Weight gain of 2 kg in one day. C. Decreased hematocrit. D. Bounding pulse. E. Flat neck veins.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason:

Jugular vein distension is a sign of fluid overload because it indicates increased pressure in the right atrium and superior vena cava due to excess blood volume.

Choice B reason:

Weight gain of 2 kg in one day is a sign of fluid overload because it reflects fluid retention in the body. A weight gain of 1 kg (2.2 lb) is equivalent to 1 L of fluid.

Choice C reason:

Decreased hematocrit is a sign of fluid overload because it indicates hemodilution or dilution of the blood due to excess fluid in the intravascular space.

Choice D reason:

Bounding pulse is a sign of fluid overload because it reflects increased cardiac output and stroke volume due to excess blood volume.

Choice E reason:

Flat neck veins are not a sign of fluid overload, but rather a sign of fluid deficit or dehydration. In fluid overload, neck veins will be distended or elevated.

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The nurse is monitoring a patient who has a central venous catheter in place for signs of complications. Which of the following are potential complications of central venous catheters? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has hyponatremia and is receiving IV fluid therapy with 3% sodium chloride solution. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse report to the provider? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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