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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Related Questions
Correct Answer is D
Explanation
corticosteroids such as prednisone are potent anti-inflammatory agents used in inflammatory conditions such as rheumatoid arthritis. This reduces the features of inflammation which include reduction of pain.
A. Prednisone reduces bone density
B. Prednisone lowers the body's immunity increasing the risk of infection
C. Prednisone increases risk of cardiovascular disease but does not directly interfere with peripheral blood
Correct Answer is A
Explanation
Rationale-Warfarin is a coumarin oral anticoagulant. Unlike heparin, warfarin has an onset of action of 4-5 days and requires this duration to give its effect. Before its action takes effect, heparin is required to bridge the gap to prevent clot formation hence the overlap period. IV heparin has no effect on the action of warfarin as an anticoagulant as they have different modes of action
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