HESI Registered Nurse EXIT Practice Exam

What sign during the placement of a central venous catheter line requires immediate attention from the nurse?

1. Pallor

2. Increased temperature

3. Dyspnea

4. Involuntary muscle spasms

The correct answer is: Dyspnea

The presence of dyspnea during the placement of a central venous catheter line indicates a potential complication, such as a pneumothorax or the catheter inadvertently entering a major airway. This situation can rapidly escalate and become life-threatening, requiring immediate intervention to ensure the patient's airway and breathing are safe. Prompt recognition and response to signs of respiratory distress are crucial in the management of the patient, as dyspnea can signal a serious issue that may necessitate thoracentesis or other emergency measures. While pallor, increased temperature, and involuntary muscle spasms are important signs to monitor, they are less immediately life-threatening compared to dyspnea. Pallor could indicate various problems, but it does not have the same urgency as respiratory distress. An increased temperature could suggest infection or inflammation but may not require immediate action in the same way. Involuntary muscle spasms may arise from several non-urgent situations, though they warrant assessment, they typically do not demand immediate response in this context.