NORCET 7 Prelims -2024
Medical & Surgical Nursing
Medium
A nurse notices swelling and a hematoma during jugular vein catheterization. What is the most appropriate initial action?
Appeared in: NORCET 7 Prelims -2024
Explanation
- Swelling and hematoma during catheterization are classic signs of vein injury, indicating blood is leaking into the surrounding tissue.
- The immediate priority, based on the principle of preventing further harm, is to stop the procedure and remove the source of the injury, which is the catheter.
- This action prevents the hematoma from enlarging and minimizes tissue damage.
- After removal, the next step is to apply direct pressure to the site to control the bleeding.
Why Other Options Were Wrong
- Option A: Continuing the procedure would exacerbate the bleeding and tissue damage, potentially leading to a larger hematoma and other complications like nerve compression.
- Option B: While documentation and notifying the doctor are crucial steps, they are not the initial priority. The immediate threat to the patient's tissue integrity must be addressed first by stopping the procedure.
- Option C: Applying ice is a secondary comfort measure to reduce swelling and pain. It does not address the primary problem, which is active bleeding from a damaged vein. The catheter must be removed first.
Related Visual
Clinical Relevance
- Nursing practice connection: Knowing Management of complications during venous catheterization helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
- Recognizing and immediately responding to complications during invasive procedures like catheterization is a critical nursing responsibility for patient safety.
- Failure to act promptly can lead to significant complications, including compartment syndrome (in an extremity), nerve damage from pressure, and skin necrosis.
- What if? If the nurse noted only slight resistance during insertion without any swelling or hematoma, the initial action would be to slightly retract or adjust the angle of the catheter, not immediate removal. If resistance persists, then removal is warranted.
How to Approach the Question
- First, identify the question type as a clinical scenario requiring a priority action.
- Analyze the key information: an invasive procedure (jugular catheterization) is in progress, and a complication has occurred (swelling and hematoma).
- Focus on the keywords 'most appropriate initial action,' which asks for the very first thing the nurse should do.
- Apply the core nursing principle of patient safety: 'first, do no harm.' The priority is to stop the process that is causing the injury.
- Evaluate each option against this principle: Continuing the procedure causes more harm. Documenting and applying ice are secondary actions. Removing the catheter is the only option that stops the cause of the harm.
- Select the option that directly and immediately addresses the cause of the complication.
Concept Tested & Keywords
- Concept Tested: Management of complications during venous catheterization.
- Stem keywords: jugular vein catheterization, swelling, hematoma, initial action
- Lead-in keywords: most appropriate, initial
- Clinical cues: The presence of both swelling and hematoma during the procedure is a clear sign of vessel injury.
Question ID
QS3KQuvp8hIYSn5qTCAqOk
Reference Book
E6 Nursing Fundamentals Taylor p. 818-820
E6 Nursing Vital Signs p. 58-60
Practise the full NORCET 7 Prelims -2024
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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