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 C

Explanation

A. Bradypnea: Bradypnea refers to abnormally slow breathing. In the context of postoperative atelectasis and hypoxia, the client is more likely to exhibit tachypnea (rapid breathing) as the body attempts to compensate for reduced oxygen levels.

B. Bradycardia: Bradycardia is an abnormally slow heart rate. While hypoxia can lead to changes in heart rate, it is more common to observe tachycardia (increased heart rate) as a compensatory response to decreased oxygen levels.

C. Intercostal retractions: Intercostal retractions occur when the muscles between the ribs pull inward during inspiration. In a client with atelectasis and hypoxia, increased respiratory effort may result in intercostal retractions as the body tries to enhance airflow and improve oxygenation.

D. Lethargy: Lethargy refers to a state of drowsiness or fatigue. While hypoxia can lead to lethargy, it is not a specific respiratory manifestation. Other respiratory signs, such as increased respiratory rate and retractions, are more likely to be observed.

A. Red-colored urine B. Black-colored stools C. Staining of teeth D. Constipation

Correct Answer is A

Explanation

A. Red-colored urine: Rifampin, when taken orally or intravenously, can cause red discoloration of bodily fluids, including urine, sweat, saliva, and tears. This is a common and harmless side effect of the medication. Clients should be informed about this potential discoloration to avoid unnecessary concern.

B. Black-colored stools: Black-colored stools are not an expected side effect of rifampin.

C. Staining of teeth: While rifampin can cause staining of contact lenses, it is not associated with tooth discoloration.

D. Constipation: Constipation is not a common side effect of rifampin. Gastrointestinal side effects may include nausea, vomiting, and abdominal pain.

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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

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expert?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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