Author Question: A client has had a subclavian central venous catheter inserted. What should the nurse assess as a ... (Read 51 times)

danielfitts88 · **on:** Jul 23, 2018

A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this client's care?

1. Presence of bibasilar crackles
2. Tachycardia
3. Decreased pedal pulses
4. Headache

Question 2

The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infant's mother?

1. Have the infant be seen by a physician
2. Give the infant at least 2 ounces of juice every 2 hours.
3. Measure the infant's urine output for 24 hours.
4. Provide the infant with 50 mL of glucose water.

cupcake16 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2
Rationale 1: Bibasilar crackles may develop secondary to fluid overload or to the disease process, but would not be particularly evident just after placement of the subclavian catheter.
Rationale 2: Because insertion of a subclavian central venous catheter may result in hemothorax, pneumothorax, cardiac perforation, thrombosis, or infection, the priority finding for planning care is tachycardia.
Rationale 3: Decrease in pedal pulses would not be associated with the placement of a subclavian catheter.
Rationale 4: Headache would not be associated with the placement of a subclavian catheter.

Answer to Question 2

Correct Answer: 1
Rationale 1: Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to health care providers for evaluation.
Rationale 2: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is juice the best choice of fluid.
Rationale 3: Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.
Rationale 4: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is glucose water the best choice of fluid.