A nurse is caring for a client who has a central venous catheter and reports hearing a gurgling sound on the side of the catheter insertion. Which of the following complications should the nurse suspect?
Catheter occlusion
Catheter migration
Catheter dislodgment
Catheter rupture
The Correct Answer is B
Choice A - Catheter Occlusion: This occurs when the catheter is blocked, preventing the flow of fluids or medication. It is usually indicated by difficulty in flushing the catheter or a slow drip rate¹. However, it does not typically cause a gurgling sound.
Choice B - (Catheter migration) is correct because when a central venous catheter (CVC) migrates from its original position, the tip can enter a smaller vein or a different location where turbulence occurs. This may cause the client to hear a gurgling or bubbling sound, especially during infusion or with position changes. Migration can happen due to coughing, movement, or changes in pressure, and it doesn’t necessarily involve the catheter being visibly out of place
Choice C - (Catheter dislodgment) is incorrect because dislodgment typically refers to the catheter being partially pulled out of the insertion site. This would be more likely to cause external signs like visible catheter movement or fluid leakage at the insertion site, rather than internal gurgling sounds. Gurgling is more associated with internal changes in catheter position, as seen with migration.
Choice D - Catheter Rupture: This is a break or tear in the catheter. It can cause serious complications, including infection and embolism. However, a gurgling sound is not a typical symptom of a catheter rupture¹.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Bradycardia is not an indication of circulatory overload. Bradycardia is a slow heart rate, usually below 60 beats per minute. Circulatory overload causes the heart to work harder to pump the excess fluid in the blood vessels, which can result in tachycardia, or a fast heart rate, usually above 100 beats per minute.
Choice B reason: Flushing is not an indication of circulatory overload. Flushing is a reddening of the skin, usually due to increased blood flow or inflammation. Circulatory overload causes the blood vessels to constrict and increase the blood pressure, which can result in pallor, or a pale appearance of the skin.
Choice C reason: Vomiting is not an indication of circulatory overload. Vomiting is the forceful expulsion of stomach contents through the mouth, usually due to nausea, infection, or irritation. Circulatory overload does not affect the gastrointestinal system directly, although it may cause abdominal distension or ascites, which is the accumulation of fluid in the abdominal cavity.
Choice D reason: Dyspnea is an indication of circulatory overload. Dyspnea is the sensation of difficulty breathing, usually due to inadequate oxygen delivery to the tissues. Circulatory overload causes the excess fluid in the blood vessels to leak into the lungs, which can result in pulmonary edema, or the accumulation of fluid in the alveoli. This impairs the gas exchange and causes hypoxia, or low oxygen levels in the blood.
Correct Answer is C
Explanation
Choice A reason: This is not a problem for a client who has hypertension and a new prescription for metoprolol, as metoprolol is a beta-blocker that can reduce the workload of the heart and improve the symptoms of heart failure.
Choice B reason: This is not a problem for a client who has hypertension and a new prescription for metoprolol, as metoprolol does not have any significant interactions with antibiotics or other medications used to treat pneumonia.
Choice C reason: This is a problem for a client who has hypertension and a new prescription for metoprolol, as tadalafil is a phosphodiesterase-5 inhibitor that can lower the blood pressure and cause hypotension when taken with metoprolol. The nurse should investigate further and notify the provider of the potential interaction.
Choice D reason: This is not a problem for a client who has hypertension and a new prescription for metoprolol, as metoprolol does not affect the blood glucose levels or the management of diabetes.
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