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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Flexing her ankles: Ankle flexion exercises and periodic ankle flexion are encouraged to promote blood circulation and prevent venous stasis, which can contribute to the development of venous thromboembolism (VTE).

B. Elevating her feet: Elevating the feet can also help prevent venous stasis and promote blood circulation. It is a recommended action to reduce the risk of VTE.

C. Massaging her legs: This is the correct answer. Massage of the legs, particularly deep tissue massage, can dislodge blood clots and increase the risk of embolization, including the risk of venous thromboembolism.

D. Ambulating soon after surgery: Early ambulation is an important preventive measure for VTE. It helps stimulate blood flow and prevents venous stasis. Encouraging the client to ambulate as soon as possible after surgery is a recommended practice.

A. "These tests help determine the degree of damage to the heart tissues." B. "Cardiac enzymes will identify the location of the MI." C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." D. "These tests will enable the provider to determine the heart structure and mobility of the heart valves."

Correct Answer is A

Explanation

A. "These tests help determine the degree of damage to the heart tissues." - This is the correct statement. Cardiac enzyme studies, such as creatine kinase (CK), CK-MB, troponin I, and troponin T, are used to assess the extent of myocardial damage during an acute myocardial infarction (MI). Elevated levels of these enzymes indicate myocardial injury and help healthcare providers determine the severity of the heart tissue damage.

B. "Cardiac enzymes will identify the location of the MI." - While cardiac enzymes can confirm the presence of an MI, they do not specifically identify the location of the infarction. Other diagnostic tools, such as electrocardiogram (ECG) and imaging studies, may help determine the location of the MI.

C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." - Cardiac enzymes are not used to diagnose pulmonary congestion. Other diagnostic methods, such as chest X-rays and physical examination, are more appropriate for assessing pulmonary congestion.

D. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." - Cardiac enzyme studies do not provide information about the overall heart structure or the mobility of heart valves. Imaging studies, such as echocardiography, are used for this purpose.

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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

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Explanation

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Correct Answer is A

Explanation

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