Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?
a. Notify the health care provider.
b. Offer reassurance to the patient.
c. Auscultate the patient's breath sounds.
d. Give the prescribed PRN morphine sulfate IV.
ANS: C
The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.
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