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.
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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Related Questions
Correct Answer is C
Explanation
Administering the blood as ordered is the right action to take. This is because type O negative blood group is a universal donor and can be safely given to all blood groups.
Completing an incident report is not necessary. This is because type O negative blood group is safe when given to recipients of all blood groups.
Contacting the provider is unnecessary at this point. The type O negative blood group is safe and hence no need for further clarification.
Type O negative blood is a universal donor and is safe in this client. It is therefore, unnecessary to notify the blood bank.
Correct Answer is B
Explanation
The client is exhibiting symptoms and signs of anaphylaxis. Anaphylaxis is a severe systemic allergic reaction that occurs due to allergens presenting with (itching) urticaria and sudden onset shortness of breath and/or shock. The first action should be to stop the infusion to prevent worsening the severity of the allergic reaction.
A. Important to allow for further prescription but not a priority
C. Auscultating the lungs allows the nurse to assess for the severity of the reaction but should come after stopping the infusion
D. Elevating the head can improve ventilation but is not a priority
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