A nurse is drawing a blood sample from a client's central line and the client suddenly becomes dyspneic and complains of chest pain. The priority action by the nurse is to
a. obtain blood pressure readings in both arms.
b. notify the physician immediately.
c. put the client in a left lateral Trendelenburg position.
d. terminate the procedure and clamp the central line.
D
This client is probably experiencing a venous air embolism from the open central line. The priority action is to stop the procedure and clamp the line. Then the nurse should position the client in Trendelenburg and rotate the client to the left side to trap the air in the apex of the heart. The nurse can attempt to aspirate the air from the distal port of the catheter. Someone else should no-tify the physician while the nurse remains with the client.
You might also like to view...
A 10-year-old child is brought to the emergency department by the rescue squad from the scene of a house fire. The child is confused and agitated. Which action by the nurse is the priority for this child?
A. Assess the child for a head injury. B. Give the child 100% oxygen. C. Obtain a complete history of the fire. D. Wait for the parents to obtain consent.
The nurse is developing a written plan of care for a patient receiving vaccines. What would be an appropriate nursing diagnosis for this patient?
A) Ineffective tissue perfusion if severe reaction occurs B) Chronic pain related to local, gastrointestinal (GI), and flu-like effects C) Monitoring effectiveness of comfort measures and adherence to the regimen D) Monitoring patient's blood serum levels
In an effort to attract clinic physicians, the hospital has agreed to provide a nurse to work in the physician's office. The nurse will work under the direction and supervision of the physician whose clinic is housed with the hospital building
Which doctrine most closely describes the conditions in which this nurse is working? 1. Borrowed servant 2. Dual servant 3. Agent of the principal 4. Independent contractor
You are a preceptor for a new nursing employee at the local hospital. She needs to access a patient's electronic health record (EHR) to retrieve laboratory results;
however, the newly hired nurse has not yet received a computer password. What action should you take? a. Give her your password to use until she obtains her own password. b. Log on and remain with her while she views the record. c. Notify your supervisor that the new employee needs a password. d. Inform her that she will not receive a password until her orientation is complete.