The nurse has been caring for a patient who has had a central venous catheter in place. The patient complains of sudden chest pain and difficulty breathing. Which assessment finding warrants immediate intervention by the nurse?
a. Exit site infection
b. Catheter-related sepsis
c. Pneumothorax
d. Hyperglycemia
C
Symptoms of pneumothorax include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on the affected side, and tachycardia. Symptoms of exit site infection include erythema, tenderness, induration, or purulence within 2 cm of the skin at the exit site. Symptoms of catheter-related sepsis include isolation of the same microorganism from a blood culture and catheter segment, with the patient showing fever, chills, malaise, and elevated white blood cell count. Symptoms of hyperglycemia include excessive thirst, urination, blood glucose greater than 160 mg/100 mL, and confusion.
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