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 B
Explanation
A. Providing immediate rest for the client: Rest is important, but in the context of an acute asthma exacerbation, addressing the underlying respiratory distress is the priority.
B. Administering a nebulized beta-adrenergic agonist: This is the correct answer. Beta-adrenergic agonists, such as albuterol, are bronchodilators that help relieve bronchoconstriction and improve airflow. Administering a nebulized beta-adrenergic agonist is a key intervention during an acute asthma exacerbation to alleviate symptoms and improve respiratory function.
C. Positioning the client in high-Fowler's: While positioning can assist with respiratory effort, administering a bronchodilator is a more direct and immediate intervention to relieve airway obstruction.
D. Initiating oxygen therapy: While oxygen therapy may be necessary, addressing bronchoconstriction with a beta-adrenergic agonist is the primary intervention during an acute asthma exacerbation.
Correct Answer is A
Explanation
A. Cellular hypoxia: Hemoglobin carries oxygen to the body's tissues. A low hemoglobin level, as well as a low hematocrit, indicates a reduced oxygen-carrying capacity of the blood, putting the client at risk for cellular hypoxia. Symptoms may include fatigue, weakness, and shortness of breath.
B. Prolonged bleeding: Hemoglobin and hematocrit levels are not directly indicative of a risk of prolonged bleeding. Prolonged bleeding is more related to platelet function and clotting factors.
C. Impaired immunity: Hemoglobin and hematocrit levels are not directly indicative of impaired immunity. Immune function is more closely associated with white blood cell count and function.
D. Fluid retention: Hemoglobin and hematocrit levels are not directly associated with fluid retention. Fluid retention is more related to factors such as sodium balance and kidney function.
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