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
Rationale:
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.
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Correct Answer is B
Explanation
Rationale:
A. The radial pulse is not as reliable as the carotid pulse in assessing circulation during CPR.
B. The carotid pulse is the most reliable site to assess circulation in an adult during CPR because it is closest to the heart and will reflect the true status of central circulation.
C. The apical pulse is not typically assessed during CPR due to its location and difficulty in palpation.
D. The popliteal pulse is not a recommended site for assessing circulation during CPR.
Correct Answer is C
Explanation
Rationale:
A. Quickly removing the family members may add to their distress and does not respect their right to decide.
B. Telling them it will be stressful assumes their reaction without giving them a choice.
C. Allowing the family members to choose whether to stay respects their autonomy and can provide comfort during a difficult time. It is also in line with current best practices for family presence during resuscitation.
D. Assigning a staff member to wait outside is appropriate but should be done after offering the family the option to stay in the room.