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

Mydriatic eye drops are used in ophthalmology to dilate the pupil for visualization of the retina and the vitreous humor. Absorption into the system an lead to systemic anticholinergic effect such a s constipation due to reduce gastrointestinal motility.

A. Bradycardia is a cholinergic effect

B and D are not typical anticholinergic effects

A. Hypoglycemia B. Hypertension C. Hypervolemia D. Hypokalemia

Correct Answer is D

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.

Hypokalemia causes complications like cardiac dysrhythmias, muscle weakness, and fatigue. The nurse should monitor the client for signs and symptoms of hypokalemia and notify the provider appropriately

A. furosemide does not affect the blood glucose levels

B. furosemide is used to lower blood pressure by reducing venous return.

C. furosemide reduces fluid load by blocking water reabsorption in the kidney

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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 receiving mydriatic eye drops. Which of the following manifestations indicates to the nurse that the client has developed a systemic anticholinergic effect?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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