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
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.
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