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. The laboratory values are the same as the previous test values: This is unlikely in DIC. In an acute episode of DIC, there is usually a significant disturbance in coagulation values due to the consumption of clotting factors and the development of clotting abnormalities.
B. The laboratory values are within the expected reference range: In DIC, the coagulation values are usually not within the expected reference range. Instead, they are prolonged, reflecting the imbalance in the coagulation system.
C. The laboratory values are prolonged: This is the correct answer. In DIC, the PT, aPTT, and INR are prolonged because the coagulation factors are being consumed in the process of widespread clot formation.
D. The laboratory values are decreased: This is not typical for DIC. In DIC, the issue is not a decrease in clotting factors but rather their consumption, leading to an overall imbalance in the coagulation system.
Correct Answer is A
Explanation
A. "It requires lying quietly on one side": This is the correct answer. During an echocardiogram, the client is typically asked to lie on their left side to obtain clear images of the heart. The test is non-invasive and involves using ultrasound waves to create images of the heart's structures.
B. "It might cause slight discomfort in the chest area": Echocardiograms are generally painless and do not cause discomfort. They are a non-invasive imaging technique that uses sound waves.
C. "It is best to have no food or beverages the day of the test": While the client may be instructed to avoid eating or drinking shortly before the test, this statement is too restrictive. The specific fasting instructions will be provided by the healthcare provider or facility.
D. "It takes about 5 or 10 minutes": The duration of an echocardiogram can vary, but it typically takes longer than 5 or 10 minutes. The test duration depends on various factors, including the complexity of the study and the information needed.
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