A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
Close the pinch clamp on the CVC.
Obtain a prescription for stat ABGS (Arterial Blood Gas Studies).
Place the client in the left Trendelenburg position.
Check the tubing for placement of a locking adaptor.
The Correct Answer is A
Choice A rationale:
The nurse's first priority in this situation should be to close the pinch clamp on the central venous catheter (CVC). This will prevent air from entering the client's vascular system and causing an air embolism, which can lead to serious complications. Once the clamp is closed, the nurse can then proceed with further assessments and interventions.
Choice B rationale:
Obtaining a prescription for stat ABGS (Arterial Blood Gas Studies) is not the first action the nurse should take in this situation. While ABGS may be relevant later to assess the client's respiratory status, the immediate concern is to prevent air embolism by closing the disconnected IV tubing.
Choice C rationale:
Placing the client in the left Trendelenburg position is not the first priority in this situation. The Trendelenburg position is used to increase venous return and is typically indicated in cases of hypotension or shock. Closing the clamp to prevent an air embolism should be the nurse's initial action.
Choice D rationale:
Checking the tubing for the placement of a locking adaptor is not the first action the nurse should take. While it is essential to ensure that the IV tubing is properly connected and secured, preventing the air from entering the CVC should take precedence in this urgent situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
10 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 1 hour. However, the question asks for the rate at which to administer 10 mEq over 1 hour, which means the total volume should be 100 mL/hr.
Choice B rationale:
50 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 2 hours. However, the question specifies 1 hour, so the rate should be higher.
Choice C rationale:
This is the correct answer. To administer 10 mEq of potassium chloride in 100 mL over 1 hour, the infusion pump should be set to deliver 100 mL/hr.
Choice D rationale:
500 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 10 minutes (1/6th of an hour). However, the question specifies 1 hour, so the rate should be much lower.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should maintain the client in a semi-Fowler's position to promote comfort and reduce the risk of complications related to appendicitis. This position helps to decrease pressure on the abdomen and may alleviate pain by reducing tension on the abdominal muscles.
Choice B rationale:
Administering an enema 1 hour prior to surgery is not indicated for a client with appendicitis. Enemas are generally not recommended for clients with suspected or confirmed appendicitis as they can potentially worsen inflammation and cause perforation of the inflamed appendix.
Choice C rationale:
Applying a warm pack to the client's lower abdomen is contraindicated in appendicitis. Heat can exacerbate inflammation and should be avoided in such cases.
Choice D rationale:
Placing the client on a clear liquid diet is not appropriate for appendicitis. Clients with appendicitis are typically NPO (nothing by mouth) to avoid stimulating the gastrointestinal tract and reduce the risk of rupture if surgery is needed.
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