The nurse is caring for a client who just had a subclavian central venous catheter inserted. Which symptom should the nurse recognize as setting a priority for this client's care?
Decreased pedal pulses
Tachycardia
Presence of bibasilar crackles
Headache
The Correct Answer is B
B. Tachycardia (elevated heart rate) can be a sign of various underlying conditions, including pain, anxiety, or cardiovascular compromise. While tachycardia may occur as a response to stress or pain associated with the catheter insertion procedure, it can also indicate complications such as hemorrhage, cardiac dysrhythmias, or pulmonary embolism, which require prompt evaluation and intervention.
A. While this can be concerning, it is not typically directly related to complications of a subclavian central venous catheter insertion unless there is evidence of arterial injury or thrombosis.
C. Bibasilar crackles are abnormal lung sounds that can indicate fluid accumulation in the lungs, such as pulmonary edema or pneumonia. However, this may not be directly related to the subclavian central venous catheter insertion itself.
D. Headache is a non-specific symptom that can have numerous causes, including stress, dehydration, or tension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. One of the primary functions of an IV infusion pump is to precisely control the rate and volume of fluid delivery, thereby reducing the risk of accidental administration of large amounts of fluids. The pump allows for accurate programming of infusion rates and volume limits, enhancing safety and preventing fluid overload or other complications.
A. Using an IV infusion pump does not eliminate the need for assessing the IV site regularly. Regardless of the infusion method, it is essential to monitor the IV site frequently for signs of complications such as infiltration, phlebitis, or dislodgement. Therefore, this option is not the appropriate rationale for using an IV infusion pump.
C. IV infusion pumps are programmable devices that allow for precise control of the drip rate independent of the client's position. They ensure a consistent and controlled flow rate regardless of changes in the client's position, providing reliable delivery of fluids or medications.
D. While IV infusion pumps can deliver fluids at various rates, including rapid infusion rates when necessary, their primary purpose is not to administer fluids at a rapid rate. Rather, they are designed to deliver fluids or medications at controlled and programmed rates tailored to the client's needs, ensuring safety and accuracy.
Correct Answer is ["B","C","D"]
Explanation
B. Increased mental acuity, or heightened alertness and cognitive function, is a characteristic response during the alarm stage of GAS. The body's stress response enhances mental focus and perception to help the individual recognize and respond to the stressor effectively.
C. During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the release of adrenaline (epinephrine) and norepinephrine. These hormones stimulate the kidneys to conserve water and sodium, leading to decreased urine output and increased urine retention. Therefore, increased urine retention is an expected physiologic manifestation in the alarm stage.
D. During the alarm stage, the sympathetic nervous system activation leads to bronchodilation, allowing for increased airflow to the lungs. This facilitates improved oxygenation of the blood and enhances the individual's ability to respond to the stressor by increasing oxygen delivery to tissues.
A. During the alarm stage of GAS, the body initiates the fight-or-flight response, which leads to the release of stress hormones such as cortisol and adrenaline. These hormones increase blood glucose levels through processes like glycogenolysis and gluconeogenesis to provide energy for the body to respond to the stressor. Therefore, decreased blood glucose is not an expected manifestation in the alarm stage.
E. Decreased pupil size: During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the dilation of pupils (mydriasis). This allows for improved visual acuity and peripheral vision, enhancing the individual's ability to detect potential threats or stimuli in the environment.
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