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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Atropine is not the correct answer, as it is an anticholinergic medication that is used to treat bradycardia, not warfarin overdose. Atropine has no effect on the INR or the coagulation cascade.

Choice B reason: Epinephrine is not the correct answer, as it is a catecholamine medication that is used to treat anaphylaxis, cardiac arrest, or severe hypotension, not warfarin overdose. Epinephrine has no effect on the INR or the coagulation cascade.

Choice C reason: Vitamin K is the correct answer, as it is the antidote for warfarin overdose. Vitamin K is a fat-soluble vitamin that is essential for the synthesis of clotting factors II, VII, IX, and X. Vitamin K can reverse the effects of warfarin and lower the INR to a therapeutic range.

Choice D reason: Protamine is not the correct answer, as it is the antidote for heparin overdose, not warfarin overdose. Protamine is a protein that binds to and neutralizes heparin, but has no effect on warfarin or the INR.

A. Reduce intake of potassium-rich foods. B. Avoid grapefruit juice. C. Take this medication before bedtime. D. Monitor for leg cramps.

Correct Answer is D

Explanation

Choice A reason: Reducing intake of potassium-rich foods is not necessary for clients taking hydrochlorothiazide, as this medication can cause hypokalemia (low potassium levels) due to increased potassium excretion in the urine. Clients may need to increase their intake of potassium-rich foods or take potassium supplements to prevent hypokalemia.

Choice B reason: Avoiding grapefruit juice is not necessary for clients taking hydrochlorothiazide, as this medication does not interact with grapefruit juice. Grapefruit juice can affect the metabolism of some other medications, such as statins, calcium channel blockers, and cyclosporine, by inhibiting the enzyme CYP3A4 in the liver.

Choice C reason: Taking this medication before bedtime is not advisable for clients taking hydrochlorothiazide, as this medication can cause increased urination and nocturia (nighttime urination). Clients should take this medication in the morning or at least 6 hours before bedtime to avoid disrupting their sleep.

Choice D reason: Monitoring for leg cramps is an important instruction for clients taking hydrochlorothiazide, as this medication can cause muscle cramps due to electrolyte imbalances, such as hypokalemia, hyponatremia (low sodium levels), or hypomagnesemia (low magnesium levels). Clients should report any signs of muscle cramps, weakness, or fatigue to their provider.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer?

Correct Answer is C

Explanation

A nurse is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the nurse indicates an understanding of the teaching?

A nurse is teaching a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include?

A nurse is caring for a client who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose?

A nurse is preparing to administer heparin to a client. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication?

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further?