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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
alcohol withdrawal can present with agitation, anxiety, seizures and hallucinations. Diazepam is a benzodiazepine that helps to control the symptoms by potentiating the inhibitory mechanisms of the brain.
A. Buprenorphine is an opioid uses in pain management.
C. Disulfiram is used in the management of alcohol use disorder
D. Methadone is an opioid used in management of pain and opioid dependence.
Correct Answer is B
Explanation
Methotrexate is immunomodulatory that inhibits DNA synthesis and repair but blocking the metabolism of DNA building blocks. In addition to it disease modifying effects on targeted tissues, it also affects rapidly dividing cells such as the bone marrow leading to reduced platelets that causes bleeding. Information on number of platelets is important to guide the next action
A-Electric brush will worsen the bleeding
C-This is important but not priority as the bleeding is likely related to the medication
D- Explaining is important but does not address the issue at hand
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