The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action?Not quite, you're still learning!Diminished breath sounds over left lung fieldLocalized pain at catheter insertion siteMeasured central venous pressure of 5 mm HgSlight bloody drainage around insertion
Question
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action?Not quite, you're still learning!Diminished breath sounds over left lung fieldLocalized pain at catheter insertion siteMeasured central venous pressure of 5 mm HgSlight bloody drainage around insertion
Solution
The assessment finding that warrants immediate action is "Diminished breath sounds over left lung field". This could indicate a pneumothorax, which is a potential complication of subclavian central venous catheter insertion. A pneumothorax occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse. This is a medical emergency and requires immediate attention.
The other options are not as immediately concerning:
- Localized pain at the catheter insertion site is expected after this procedure.
- A measured central venous pressure of 5 mm Hg is within the normal range (2-8 mm Hg).
- Slight bloody drainage around the insertion site can be expected after the procedure. However, if the drainage increases or does not stop, this could indicate a problem.
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