Fundamentals of Nursing Q 384
A nurse is caring for a combative client who is ordered to have a nutritional therapy using parenteral nutrition (PN). The nurse should plan which of the following measures to prevent the client from injury?
A. Monitor blood glucose twice a day.
B. Instruct the relative to stay with the nurse.
C. Measure 24-hour intake and output.
D. Secure all connections in the parenteral system.
Correct Answer: D. Secure all connections in the parenteral system.
The nurse should plan to secure all connections in the tubing. This will prevent the client from pulling the connections apart. An air embolism may occur if IV tubing disconnects and is open to air, or if part of the catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.
Option A: The nurse may monitor the blood glucose but it is unrelated to the situation. Many fatal instances of air emboli in patients with central venous catheters have been reported in the literature. They frequently occur when the tubing becomes tangled while a patient is getting out of bed, causing the catheter to disconnect. Although less common, cracks in the catheter hub can also allow air to enter the venous system.
Option B: The relative may stay with the patient when necessary. Central venous catheters are also used in applications other than TPN. These include central venous pressure monitoring, rapid infusion of fluids, pulmonary arterial pressure monitoring using Swan-Ganz catheters, and hemodialysis. Also, a central venous catheter is often placed in the right atrium during surgery to remove air that might be introduced elsewhere in the venous system. It is possible for an air embolism to develop during all of these central venous applications.
Option C: Measuring the I&O of the patient is not related to the situation. An air embolism can develop when the right side of the heart is open to outside air through a disconnected catheter and a negative intrathoracic pressure is present, such as during inspiration. The right side of the heart is open to outside air when the catheter is first inserted and during catheter changes.