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. "This test will help my provider adjust my warfarin dosages": aPTT is not typically used to monitor warfarin therapy. Instead, it is more commonly associated with monitoring heparin therapy.
B. "If my levels are too low, I am at an increased risk for bleeding": This statement is inaccurate. Low levels of clotting factors could lead to a prolonged aPTT, which might increase the risk of bleeding.
C. "It measures deficiencies in clotting factors."
Activated partial thromboplastin time (aPTT) is a laboratory test that evaluates the intrinsic pathway of the coagulation cascade. The aPTT measures the time it takes for a clot to form and reflects the activity of various clotting factors, including factors VIII, IX, XI, and XII. An elevated aPTT may indicate a deficiency or dysfunction of one or more clotting factors.
D. "I will need to skip breakfast until after the test is complete": There is no need for the client to skip breakfast before an aPTT test. The test is not affected by food intake.
Correct Answer is D
Explanation
A. Nausea: While respiratory distress can lead to various symptoms, nausea is not a typical manifestation of hypoxemia during an asthma attack.
B. Dysphagia: Difficulty swallowing (dysphagia) is not a direct manifestation of hypoxemia during an asthma attack. Asthma primarily affects the airways and respiratory function.
C. Hypotension: Hypotension (low blood pressure) is not typically associated with hypoxemia during an asthma attack. In fact, increased respiratory effort and stress can lead to increased heart rate and, in some cases, increased blood pressure.
D. Agitation: This is the correct answer. Hypoxemia, which occurs when there is an inadequate amount of oxygen in the blood, can lead to increased restlessness, anxiety, and agitation. Agitation is a common manifestation of the body's response to insufficient oxygenation.
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