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 D
Explanation
Rationale:
A. This response may make the spouse feel pressured by implying that religion should not be a concern, which may not be respectful of the spouse's beliefs.
B. This statement is coercive, focusing on the shortage of organs rather than on the spouse's feelings and the wishes of the deceased.
C. Suggesting that donating organs will make the spouse feel better can be seen as manipulative and may not truly address the spouse's confusion or emotions.
D. Asking what the spouse thinks the deceased would have wanted is appropriate, as it centers on the values and wishes of the deceased, which can guide the spouse in making an informed decision.
Correct Answer is D
Explanation
Rationale:
A. A coronary artery bypass graft is used to treat coronary artery disease but is not typically indicated for end-stage heart failure.
B. Percutaneous coronary intervention is also used for coronary artery disease, not for improving quality of life in terminal heart failure.
C. This option dismisses potential interventions that could improve quality of life, such as an LVAD.
D. An LVAD is a mechanical pump that assists the left ventricle in pumping blood, often used as a bridge to heart transplant or as a long-term solution to improve quality of life in patients with terminal heart failure.