A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?
“The client needs immediate intubation and mechanical ventilation."
"Maybe the client has respiratory distress syndrome."
"The client is breathing too slowly and it interferes with oxygenation."
"The blood clot interferes with perfusion in the lungs."
The Correct Answer is D
A. “The client needs immediate intubation and mechanical ventilation.” Intubation may be required in severe respiratory failure, but not all clients with pulmonary embolism need mechanical ventilation. Suggesting intubation without assessment of the client’s respiratory effort or ABGs is premature.
B. "Maybe the client has respiratory distress syndrome." ARDS is can impair oxygenation, but it is not the most likely explanation for persistent low oxygen saturation in PE. PE more commonly causes ventilation-perfusion mismatch due to blocked blood flow.
C. "The client is breathing too slowly and it interferes with oxygenation." Slow breathing could impair ventilation, but in PE, oxygenation is impaired because blood flow to parts of the lung is blocked, not necessarily due to a respiratory rate issue.
D. "The blood clot interferes with perfusion in the lungs." Pulmonary embolism obstructs blood flow in the pulmonary arteries, resulting in areas of the lung being ventilated but not perfused. This causes a ventilation-perfusion mismatch and leads to reduced oxygenation despite supplemental oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assess the posterior pharynx for active bleeding:Frequent throat clearing without reported pain after a tonsillectomy may indicate active bleeding, which can be life-threatening. Silent bleeding may drip down the throat and trigger subtle clearing rather than coughing or spitting, making visual inspection an immediate priority.
B. Place the client in the side lying position:Side-lying can help prevent aspiration if bleeding occurs, but it does not replace the need to directly assess for bleeding first. Positioning should follow an initial airway and bleeding assessment.
C. Give the client juice through a straw:Using a straw is discouraged after tonsillectomy because the suction motion can disrupt clots and provoke bleeding. Juice may be appropriate for hydration, but not with a straw and not before checking for bleeding.
D. Offer the client ice cream to coat the throat:Cold soft foods like ice cream may soothe the throat and reduce swelling, but this should not be the first action when silent bleeding is suspected. The priority is ensuring that no active bleeding is occurring before offering food.
Correct Answer is D
Explanation
A. Temperature of 101.8°F:A temperature above 100.4°F indicates continued fever and inflammation, suggesting the infection is still active. A persistent fever does not reflect clinical improvement and may warrant further assessment or intervention.
B. WBC count of 17,500/mm³:An elevated white blood cell count suggests ongoing infection or inflammation. Normal WBC counts typically range from 4,000 to 11,000/mm³. This elevated value indicates the body is still actively fighting an illness.
C. Respiratory rate of 28:A normal adult respiratory rate is 12–20 breaths per minute. A rate of 28 suggests the patient is still experiencing respiratory distress, possibly due to hypoxia or infection, which does not indicate improvement.
D. Oxygen saturation of 94% on 2L/nasal cannula:An SpO₂ of 94% on low-flow oxygen shows that the patient is maintaining adequate oxygenation with minimal support. This indicates an improving respiratory status and better gas exchange, reflecting clinical progress.
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