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 D

Explanation

A. A friction rub:A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.

B. A split second heart sound S₂:A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.

C. The third heart sound (S3):S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.

D. The fourth heart sound (S4):S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.

A. Smoking cessation B. Regular moderate exercise C. Maintenance of ideal weight D. Annual influenza immunization

Correct Answer is A

Explanation

A. Smoking cessation: Chronic bronchitis is often associated with smoking and exposure to tobacco smoke. The most effective preventive measure for chronic bronchitis is to quit smoking and avoid exposure to secondhand smoke. Smoking cessation not only prevents chronic bronchitis but also improves overall respiratory health.

B. Regular moderate exercise: While regular exercise is beneficial for overall health, it is not specifically cited as a primary preventive measure for chronic bronchitis. However, exercise can contribute to overall respiratory health and well-being.

C. Maintenance of ideal weight: Maintaining an ideal weight is important for overall health, but it is not identified as a specific preventive measure for chronic bronchitis.

D. Annual influenza immunization: Influenza immunization is important for preventing influenza (flu) and its complications. While individuals with chronic bronchitis may be at increased risk for respiratory infections, annual influenza immunization is not a direct preventive measure for chronic bronchitis itself.

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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

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Explanation

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