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 A

Explanation

A. Cellular hypoxia: Hemoglobin carries oxygen to the body's tissues. A low hemoglobin level, as well as a low hematocrit, indicates a reduced oxygen-carrying capacity of the blood, putting the client at risk for cellular hypoxia. Symptoms may include fatigue, weakness, and shortness of breath.

B. Prolonged bleeding: Hemoglobin and hematocrit levels are not directly indicative of a risk of prolonged bleeding. Prolonged bleeding is more related to platelet function and clotting factors.

C. Impaired immunity: Hemoglobin and hematocrit levels are not directly indicative of impaired immunity. Immune function is more closely associated with white blood cell count and function.

D. Fluid retention: Hemoglobin and hematocrit levels are not directly associated with fluid retention. Fluid retention is more related to factors such as sodium balance and kidney function.

A. "DIC is controllable with lifelong heparin usage." B. "DIC is caused by abnormal coagulation involving fibrinogen." C. "DIC is a genetic disorder involving a vitamin K deficiency." D. "DIC is characterized by an elevated platelet count."

Correct Answer is B

Explanation

A. "DIC is controllable with lifelong heparin usage": This statement is not accurate. While heparin may be used in the treatment of DIC, it is not a lifelong therapy, and the approach to treatment depends on the underlying cause.

B. "DIC is caused by abnormal coagulation involving fibrinogen": This is the correct answer. DIC is a condition characterized by widespread activation of the clotting cascade, leading to the formation of microthrombi throughout the body. Abnormal coagulation involves the consumption of clotting factors, including fibrinogen.

C. "DIC is a genetic disorder involving a vitamin K deficiency": This statement is not accurate. DIC is not a genetic disorder, and it is not primarily related to vitamin K deficiency. It is an acquired condition often associated with severe infections, sepsis, trauma, or other critical illnesses.

D. "DIC is characterized by an elevated platelet count": This statement is not accurate. In DIC, there is often a decrease in platelet count due to consumption and activation of platelets in the widespread formation of microthrombi.

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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

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