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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Verify that the client has adequate IV access.

Choice A rationale:

Administering vasopressin to the client might be necessary to manage the hemorrhage, but before any medication administration, it is crucial to ensure the client has adequate IV access. Vasopressin is a vasoconstrictor and can help control bleeding from esophageal varices, but its effectiveness relies on IV access to deliver the medication promptly.

Choice B rationale:

Requesting blood from the blood bank is essential for a client experiencing significant bleeding. However, the priority action is to verify IV access to administer any necessary blood products.

Choice C rationale:

This is the correct choice. Before initiating any interventions, ensuring the client has appropriate IV access is a priority. Adequate IV access is necessary to administer fluids, medications, or blood products promptly and effectively stabilize the client's blood pressure.

Choice D rationale:

Inserting an indwelling urinary catheter is not the priority action in this situation. While monitoring urine output is important, it should be secondary to addressing the client's hypotension and hemorrhage.

A. INR 0.8, aPTT 85 seconds. B. INR 2, aPTT 60 seconds.

Correct Answer is B

Explanation

Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client who has a deep vein thrombosis and a prescription for heparin. For which of the following findings should the nurse withhold the medication and notify the provider?

Correct Answer is B

Explanation

A nurse in an emergency department is providing care for a client who has a subdural hematoma. The nurse should identify that which of the following is the earliest manifestation of a change in neurological status?

A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?

A nurse is preparing a client for discharge who was admitted for diabetic ketoacidosis. Which of the following statements should the nurse include in the discharge teaching?

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A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?

A nurse in the emergency department is preparing to irrigate the eyes of a client who received a chemical splash on their face. Which of the following actions should the nurse take?

A nurse is caring for a client who has a new colostomy. Which of the following statements should the nurse include in educating the client regarding colostomy care?

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