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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A history of gastric ulcers is a contraindication to the use of aspirin. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate the stomach lining and increase the risk of gastrointestinal bleeding and ulcers. Therefore, in a client with a history of gastric ulcers, aspirin should be avoided to prevent exacerbation of the condition and potential complications.
A, B, D - Migraine headaches, glaucoma and amenorrhea are not contraindications to aspirin use
Correct Answer is A
Explanation
Cushing's Triad is a set of clinical signs associated with increased intracranial pressure (ICP) and typically includes hypertension (widening pulse pressure), bradycardia, and irregular respirations. Mannitol is an osmotic diuretic that works by drawing water out of brain tissue and into the bloodstream, thereby reducing cerebral edema and intracranial pressure.
B, C, D have no role in raised intracranial pressure
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