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
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Blood group type AB individuals are considered universal recipients and can receive blood from donors of any ABO blood type without experiencing an adverse reaction. Since the client has type AB blood and the unit of blood available is type B, there is no blood type incompatibility, and the nurse can safely administer the blood as ordered.
A. Completing an incident report is not necessary in this situation as there is no discrepancy or error.
B. There is no discrepancy in this scenario, so notifying the blood bank is unnecessary.
C. Contacting the provider for further orders is not required in this situation.
Correct Answer is C
Explanation
Montelukast is a leukotriene receptor antagonist used for the long-term control of asthma. Among the side effects, montelukast causes drowsiness and hence should be taken at night before bed to avoid interference with daily activities.
A. Montelukast is an oral preparation that does not require a spacer unlike inhalers such as salbutamol
B. Montelukast is used controller therapy rather than a reliever in acute asthmatic attack
D. Rinsing the mouth is relevant in the use of inhaled corticosteroids to prevent oral thrush but not montelukast.
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