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 C

Explanation

Diphenhydramine is an oral antihistamine used in pruritus. Its main side effect is sedation and hence its recommended for use at bedtime to prevent daytime somnolence.
A. Taking the medication with meals does not reduce daytime sedation.
B. Gradually decreasing the dose once tolerance to the effect is reached may be appropriate in some cases, but it does not address immediate concerns about daytime sedation.
D. Distributing the doses evenly throughout the day may not effectively minimize daytime sedation.

A. “Stop taking the pills and switch to a different contraceptive method” B. "Take a home pregnancy test. C. "Do not have vaginal intercourse until after your next period." D. "Take the missed dose now, then continue the medication as ordered."

Correct Answer is D

Explanation

During the first week or last week of a 28-day cycle pack of oral contraceptives increases the risk of contraceptive failure. However, the client should take the missed dose as soon as they remember, even if it means taking two pills in one day. After taking the missed dose, the client should continue taking the remaining pills in the pack at the usual time, one pill per day. Due to increased risk of failure, client should use an emergency pill or condom for the next 7 days
A -stopping the pills and switching to a different contraceptive method is not necessary after missing one dose
B –missing a pill does not automatically indicate pregnancy. Testing can be considered in presence of typical signs and symptoms of pregnancy
C- abstaining from vaginal intercourse until after the next period is not necessary. Risk of pregnancy can be addressed by use of back up contraception like condoms.

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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

A nurse is caring for a client Who is prescribed diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse give?

Correct Answer is C

Explanation

A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide?

Correct Answer is D

Explanation

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