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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A."I will follow a daily diet high in calories and protein": While maintaining adequate nutrition is important, emphasizing a diet high in calories may not be suitable. A balanced diet, including adequate protein, is recommended.

B."I will avoid getting a flu shot": Individuals with emphysema are at an increased risk of respiratory infections, including influenza. Getting a flu shot is generally recommended to reduce the risk of infection and complications.

C. "I will inhale slowly through pursed lips to help me breathe better."
This statement reflects a correct understanding of a beneficial breathing technique for individuals with emphysema. Inhaling slowly through pursed lips can help create back pressure in the airways, preventing them from collapsing and promoting better air exchange in the lungs. This technique can assist in managing shortness of breath and improving overall respiratory function.

D."I will lie on my stomach to practice abdominal breathing every day": While practicing abdominal breathing can be beneficial, lying on the stomach may not be the most practical or comfortable position for this purpose. The emphasis should be on proper breathing techniques, which can be done in various positions, including sitting or standing.

A. The student needs to go to the hospital. B. The nurse should obtain a second expiratory flow rate. C. The student's peak flow is 50% to 80% of his best peak flow. D. The student should use his quick-relief inhaler. E. The student's asthma is not well controlled,

Correct Answer is ["B","C","D","E"]

Explanation

Asthma action plans often use a color-coded system to guide management based on peak expiratory flow rate (PEFR) measurements. The zones are typically green (80-100% of personal best), yellow (50-79% of personal best), and red (less than 50% of personal best).

A. The student needs to go to the hospital.

This is not necessarily required when the student is in the yellow zone. The yellow zone indicates caution and the need for intervention, but it does not immediately require hospitalization unless symptoms worsen or do not improve after using the quick-relief inhaler.

B. The nurse should obtain a second expiratory flow rate.

Confirming the peak flow measurement with a second reading ensures accuracy and helps to make informed decisions about the student's asthma management.

C. The student should use his quick-relief inhaler.

In the yellow zone, indicating moderate impairment, the use of a quick-relief (rescue) inhaler is often recommended to relieve symptoms and prevent progression to the red zone.

D. The student's peak flow is 50% to 80% of his best peak flow.

This is the correct range for the yellow zone, indicating moderate impairment. Action is needed to prevent worsening.

E. The student's asthma is not well controlled.

Being in the yellow zone indicates that the asthma is not well controlled and may require adjustments in the long-term management plan, including possible changes to daily controller medications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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