Question

A very active 2-year-old child pulls out a tunneled central venous catheter. What initial nursing action is most appropriate?

A
Obtain emergency equipment.
B
Assess heart rate, rhythm and all pulses.
C
Use cold packs at the exit incision site.
D
Apply pressure to the vessel insertion site.

Answer 1

A very active 2-year-old child pulls out a tunneled central venous catheter. A. Obtain emergency equipment initial nursing action is most appropriate.

Step-by-step explanation:

The most appropriate initial nursing action when a very active 2-year-old child pulls out a tunneled central venous catheter is to obtain emergency equipment. This action prioritizes the preparation for potential complications and ensures that the necessary tools and resources are readily available for immediate intervention.

When a central venous catheter is dislodged, there is an increased risk of bleeding, infection, and other complications. Obtaining emergency equipment allows the nurse to be prepared for any immediate life-threatening situations that may arise, such as severe bleeding. This may include sterile dressings, pressure dressings, and supplies for securing a new catheter if needed.

After obtaining emergency equipment, further assessments and interventions can be initiated. Assessing heart rate, rhythm, and pulses (Option B) is important but may follow the immediate need for equipment. Using cold packs at the exit incision site (Option C) or applying pressure to the vessel insertion site (Option D) are not the primary actions in this situation and could potentially delay necessary interventions.

In summary, obtaining emergency equipment is the most crucial initial nursing action to address the immediate risks associated with a pulled-out tunneled central venous catheter in a very active 2-year-old child.

Answer 2

The most appropriate initial nursing action when a child pulls out a tunneled central venous catheter is to apply pressure to the vessel insertion site to control bleeding and prevent air embolism.

Step-by-step explanation:

When a child has inadvertently pulled out a tunneled central venous catheter, it is critical to address the potential for bleeding and venous air embolism. The most appropriate initial nursing action is to apply pressure to the vessel insertion site. This step helps to control bleeding and prevent air from entering the venous system. Once pressure has been applied, the nurse should then proceed to assess the patient's vitals, including heart rate and rhythm, and all pulses, and prepare to support the patient with emergency equipment if necessary. Cold packs at the exit site may be considered later on for swelling or pain, but the immediate priority is to mitigate the risks of hemorrhage and air embolism.