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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Bradypnea B. Bradycardia C. Intercostal retractions D. Lethargy

Correct Answer is C

Explanation

A. Bradypnea: Bradypnea refers to abnormally slow breathing. In the context of postoperative atelectasis and hypoxia, the client is more likely to exhibit tachypnea (rapid breathing) as the body attempts to compensate for reduced oxygen levels.

B. Bradycardia: Bradycardia is an abnormally slow heart rate. While hypoxia can lead to changes in heart rate, it is more common to observe tachycardia (increased heart rate) as a compensatory response to decreased oxygen levels.

C. Intercostal retractions: Intercostal retractions occur when the muscles between the ribs pull inward during inspiration. In a client with atelectasis and hypoxia, increased respiratory effort may result in intercostal retractions as the body tries to enhance airflow and improve oxygenation.

D. Lethargy: Lethargy refers to a state of drowsiness or fatigue. While hypoxia can lead to lethargy, it is not a specific respiratory manifestation. Other respiratory signs, such as increased respiratory rate and retractions, are more likely to be observed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

Correct Answer is C

Explanation

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expert?

Correct Answer is C

Explanation

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include?

A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?