A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which of the following would be the initial nursing action?
Initiate an intravenous line
Assess the client's blood pressure
Prepare to administer Morphine sulfate
Administer oxygen at 8 to 10L/min by face mask
The Correct Answer is D
A. Initiate an intravenous line: Establishing IV access is important for administering medications or fluids, but immediate oxygenation takes priority to prevent hypoxia and tissue damage in a suspected pulmonary embolism.
B. Assess the client's blood pressure: Monitoring vital signs, including blood pressure, is essential for detecting hemodynamic instability, but it is secondary to ensuring adequate oxygenation in the acute phase of a pulmonary embolism.
C. Prepare to administer Morphine sulfate: Morphine may relieve pain and anxiety, but it does not address the primary threat of hypoxemia or impaired oxygen delivery, making it a lower priority intervention.
D. Administer oxygen at 8 to 10L/min by face mask: Supplemental oxygen helps maintain adequate oxygen saturation, reduces hypoxemia, and supports vital organ perfusion. In a client with sudden dyspnea and tachycardia suggestive of a pulmonary embolism, rapid oxygen delivery is the immediate priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Place a pillow under the child's head: Supporting the head can prevent minor trauma during a seizure, but it does not address immediate risks in the environment that could cause serious injury.
B. Loosen restrictive clothing: Loosening tight clothing can improve comfort and prevent airway restriction, yet it is secondary to ensuring the child’s safety from environmental hazards.
C. Clear the area of hazards: The priority during a seizure is to prevent injury. Removing sharp objects, furniture, or other obstacles protects the child from trauma caused by uncontrolled movements and ensures a safer environment while other supportive interventions are implemented.
D. Position the child on his side: Placing the child on their side helps maintain airway patency and reduces the risk of aspiration. While essential, it is most effective after the immediate environment is made safe, making hazard clearance the initial priority.
Correct Answer is D
Explanation
A. Herpes: Genital herpes is caused by herpes simplex virus (HSV) and is a lifelong viral infection. Antiviral medications can manage outbreaks and reduce transmission but cannot cure the infection.
B. Acquired imunodeficiency syndrome (AIDS): AIDS is caused by HIV, which is a chronic viral infection. Antiretroviral therapy controls viral replication and improves immune function but does not eradicate the virus.
C. Venereal warts: Caused by human papillomavirus (HPV), genital warts can be treated or removed, but the underlying viral infection may persist. Recurrence is common, and no definitive cure exists.
D. Chlamydia: Chlamydia trachomatis is a bacterial infection that can be effectively treated and cured with antibiotics such as azithromycin or doxycycline when the full course is completed, preventing long-term complications.
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