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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
It is recommended that every injection of phenytoin be followed by infusion of at least 50 to 100mls of normal saline infusion. This is important to prevent local irritation that occurs as surrounding tissues react to the medication.
A. Mixing phenytoin in dextrose 5% is not recommended due risk of precipitation of the Phenytoin acid
C. Phenytoin should be given at a date of 50mg/min or less to reduce the risk of toxicity
D. The injection should not be held as it is used to manage the seizure unless it is not safe for the nurse to give it
Correct Answer is A
Explanation
Furosemide is a loop diuretic that blocks water reabsorption in the loop of Henle promoting diuresis. It also causes potassium loss in urine leading to hypokalemia. Checking potassium levels before administration of furosemide prevents worsening already existing hypokalemia.
B, C, D- furosemide does not affect the blood levels of phosphate, Carbon dioxide and bicarbonate.
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