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 B
Explanation
When using multiple eye drops, it's generally recommended to wait at least 5 minutes between administering each medication. This helps prevent dilution of the medication and improves its absorption.
A is incorrect because holding pressure on the conjunctival sac after administering eye drops is not necessary and may increase systemic absorption of the medication.
C is incorrect because contact lenses should typically be removed before administering eye drops to prevent interference with the medication reaching the eye.
D is incorrect because touching the tip of the dropper to the sclera of the eye can contaminate the dropper tip and increase the risk of infection. It's important to administer eye drops without touching the tip to the eye or any other surface.
Correct Answer is C
Explanation
Rifampin causes harmless discoloration of bodily fluids, including urine, sweat, saliva, and tears, to an orange-red color. Other side effects include gastrointestinal side effects such as nausea, vomiting, and diarrhea.
A. Rifampin should be taken on an empty stomach, as food can interfere with its absorption.
B. Insomnia is not a common side effect of rifampin
D. Treatment for tuberculosis goes on for at least 6 to 9 months. Treatment duration varies depending on the specific regimen and the severity of the infection.
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