A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?

Clamp the catheter.

Position the client in left lateral Trendelenburg.

Auscultate breath sounds.

Initiate oxygen therapy.

Answer and Explanation

The Correct Answer is A

Acute shortness of breath in a client with a central venous catheter could be secondary to various respiratory complications such as pulmonary embolism and pneumothorax. Taking the appropriate action requires a quick assessment through auscultation as the emergency management of the various complications is different.
A. This is the immediate action to prevent more air from entering the venous system.
B. The left lateral trendelenburg position is relevant in hypotension but not a priority action.

C. uscultating breath sounds is an important assessment, especially if the cause of the shortness of breath is unclear. It can help identify wheezing, crackles, or absence of breath sounds, which may suggest conditions like pneumothorax, pulmonary embolism, or infection. However, while auscultation is an important diagnostic step, it is typically done after initial interventions (such as positioning or administering oxygen) to stabilize the client.
D. Initiating oxygen therapy is important in cases of respiratory distress but assessment is priority in this case

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Correct Answer is C

Explanation

Rationale- Grape fruit inhibits the action of intestinal enzymes interfering with absorption and actions of most drugs. It is therefore, important for clients on oral medication to avoid the intake of grape fruit to allow optimal absorption of the drugs.

A, B, D- Have very minimal drug interactions and hence safe to take with most medications

A. Discard regular insulin that appears cloudy. B. Shake the NPS insulin until it is well mixed. C. Inject air into the regular insulin first. D. Draw up the NPR insulin into the syringe first.

Correct Answer is A

Explanation

The normal appearance of regular insulin should be clear and colorless. Cloudy appearance or presence of particles indicates that the insulin has precipitated and may not be effective.
B. NPH insulin should be gently rolled between the palms to mix it but not shaken as this can lead to foaming and inaccuracy of the dose.
C. Injecting air into regular insulin first is not necessary. This step is typically done when drawing up NPH insulin to prevent the formation of air bubbles in the vial.
D. Regular insulin should be drawn up first to prevent contamination with the intermediate acting form of insulin

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A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?

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