A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?
Remove the catheter.
Replace the infusion system.
Prepare for chest tube insertion.
Place the client on his left side in Trendelenburg position.
The Correct Answer is D
A. Remove the catheter: Removing the catheter may not be the immediate priority. The nurse should focus on preventing further air entry into the circulation and addressing the symptoms.
B. Replace the infusion system: While ensuring that the infusion system is intact is important, it is not the primary action needed to manage an air embolism.
C. Prepare for chest tube insertion: Chest tube insertion is not the primary intervention for an air embolism. The focus should be on preventing the progression of the embolism and providing supportive care.
D. Place the client on his left side in Trendelenburg position: This is the correct answer. Placing the client on the left side in Trendelenburg position is a maneuver used to trap air in the right atrium, preventing it from traveling to the pulmonary artery. The left side position helps to prevent the air from traveling to the right ventricle and into the pulmonary artery, reducing the risk of further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. High-density lipoprotein (HDL) level of 70 mg/dL: Having a high HDL level is generally considered a protective factor against cardiovascular disease, including hypertension.
B. A diet high in potassium: A diet high in potassium is often associated with a lower risk of hypertension. Potassium helps balance sodium levels and supports healthy blood pressure.
C. Obstructive sleep apnea (OSA): This is the correct answer. Obstructive sleep apnea is a known risk factor for hypertension. The repeated episodes of interrupted breathing during sleep can contribute to increased blood pressure.
D. Taking benazepril: Benazepril is an angiotensin-converting enzyme (ACE) inhibitor commonly used to treat hypertension. While it is used to manage high blood pressure, taking the medication itself is not a risk factor for developing hypertension.
Correct Answer is A
Explanation
A. Excessive thrombosis and bleeding
Disseminated Intravascular Coagulation (DIC) is a complex and serious condition characterized by widespread activation of the coagulation cascade, leading to both excessive clot formation (thrombosis) and simultaneous consumption of clotting factors and platelets, resulting in bleeding. DIC can occur as a secondary complication to various conditions such as sepsis, trauma, or obstetric complications.
B. Increased clotting factors: In DIC, there is consumption and depletion of clotting factors, not an increase.
C. Progressive increase in platelet production: Platelet production does not increase in DIC; instead, there is consumption and decreased platelet count.
D. Immediate sodium and fluid retention: DIC is not associated with immediate sodium and fluid retention; instead, it is characterized by fluid loss due to bleeding.
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