A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?

Clamp the catheter.

Position the client in left lateral Trendelenburg.

Auscultate breath sounds.

Initiate oxygen therapy.

Answer and Explanation

The Correct Answer is A

Acute shortness of breath in a client with a central venous catheter could be secondary to various respiratory complications such as pulmonary embolism and pneumothorax. Taking the appropriate action requires a quick assessment through auscultation as the emergency management of the various complications is different.
A. This is the immediate action to prevent more air from entering the venous system.
B. The left lateral trendelenburg position is relevant in hypotension but not a priority action.

C. uscultating breath sounds is an important assessment, especially if the cause of the shortness of breath is unclear. It can help identify wheezing, crackles, or absence of breath sounds, which may suggest conditions like pneumothorax, pulmonary embolism, or infection. However, while auscultation is an important diagnostic step, it is typically done after initial interventions (such as positioning or administering oxygen) to stabilize the client.
D. Initiating oxygen therapy is important in cases of respiratory distress but assessment is priority in this case

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Correct Answer is A

Explanation

Following traumatic brain injury, the cerebral tissues undergoes an inflammatory process in response to the trauma leading to brain edema. This increases intracranial pressure which presents with features such as seizures, headaches and other focal neurological deficits. Mannitol is an osmotic diuretic that works by drawing water out of brain tissue and into the bloodstream, thereby reducing cerebral edema and intracranial pressure.
B, C, D have no role in raised intracranial pressure

A. 'Glipizide absorbs the excess carbohydrates in your system." B. "Glipizide prevents your liver from destroying your insulin." C. "Glipizide stimulates pancreas to release insulin." D. "Glipizide replaces insulin that is not being produced by the pancreas."

Correct Answer is C

Explanation

Rationale- Glipizide is an oral hypoglycemic agent. It belongs to a class of drugs referred to as sulfonyl ureas. It acts on the beta cells of the pancreases to stimulate release of insulin. This helps the body in lowering blood glucose levels appropriately.
A. Glipizide help in lowering blood sugars after carbohydrate metabolism, it does not directly absorb excess carbohydrates in the system.
B. Glipizide has no effect on the liver
D. Glipizide stimulates the pancreas to release more insulin but not to replace- it is not an insulin

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A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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