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

Phenytoin is a lifelong medication for clients presenting with unprovoked seizures. The statement shows that the client has not understood their current management plan or is in denial and requires further counselling to promote adherence.

B.Notifying the doctor before taking any other medication is important as certain drug interactions can lead to toxicity of inadequate blood levels of phenytoin.

C.This is correct as it shows understanding that phenytoin can cause oral adverse effects such as gingival hyperplasia

D.Shows understanding that some drug preparations could have incipient that may cause adverse effects that the originally tolerated agent

A. A severe allergy to amoxicillin B. A recent history of diarrhea for 3 days C. A history of phlebitis following an IV infusion of 0.9% sodium chloride with 10 mEq of potassium chloride D. Serum creatinine 0.8 mg/Dl

Correct Answer is A

Explanation

Cefoxitin is a cephalosporin with potential cross reactivity with penicillins (amoxicillin)and hence must be avoided in known history of penicillin allergy
B. A recent history of diarrhea for 3 days is not a contraindication for the administration of cefoxitin.
C. A history of phlebitis following an IV infusion of 0.9% sodium chloride with 10 mEq of potassium chloride is not directly related to the administration of cefoxitin.
D. A serum creatinine level of 0.8 mg/dL is within the normal range

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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 performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who is to receive the first dose of cefoxitin via intermittent IV bolus. Which of the following findings should the nurse identify as a contraindication for the client to receive cefoxitin and report to the provider?

Correct Answer is A

Explanation

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