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 A
Explanation
A. Continuous IV infusion is the most appropriate route for treating hypertensive emergencies because it allows for rapid and controlled reduction of blood pressure, which is crucial in preventing target organ damage.
B. Sublingual administration is not recommended in hypertensive emergencies because it does not allow for the precise control needed in these situations.
C. Intramuscular administration is generally not used for antihypertensive agents in emergencies because it does not provide the rapid and adjustable response that IV infusion does.
D. Oral administration is too slow in onset for hypertensive emergencies and is not appropriate when immediate blood pressure control is necessary.
Correct Answer is B
Explanation
A. There is no time to wait for a DNR order in an emergency; immediate action is needed.
B. Without a written DNR order, the nurse is legally and ethically obligated to initiate CPR and call the emergency response team to attempt to save the client’s life.
C. Contacting the risk manager is not an immediate action that would benefit the patient in this emergency situation.
D. The family’s wishes cannot be respected in this scenario without a formal DNR order in place; thus, the nurse must perform CPR.
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