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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Toddlers engage in parallel play: Between ages 1 and 3, toddlers typically play alongside peers without direct interaction, known as parallel play. This allows them to observe and imitate social behaviors while developing motor skills and independence, which is developmentally appropriate for this age group.
B. Toddlers engage in cooperative play: Cooperative play, where children actively interact, share, and collaborate toward a common goal, usually emerges in the preschool years around ages 3–4. Toddlers generally lack the cognitive and social maturity for sustained cooperative play.
C. Toddlers do not engage in play outside the home: This statement is inaccurate, as toddlers naturally explore environments both inside and outside the home. Outdoor play provides sensory stimulation, gross motor development, and opportunities for social observation.
D. Toddlers engage in solitary play: Solitary play is more characteristic of infants and very young toddlers under 12 months. By 1–2 years, most toddlers begin engaging in parallel play rather than playing entirely alone.
Correct Answer is C
Explanation
A. Rash on face: While some rashes may accompany infections, a localized facial rash in a neonate is nonspecific and can result from benign conditions such as erythema toxicum neonatorum, making it less indicative of systemic sepsis.
B. Edematous neck: Neck edema is uncommon in neonates and may suggest local trauma, lymphatic obstruction, or congenital anomalies rather than sepsis. It does not provide reliable evidence of systemic infection.
C. Hypothermia: Neonates with sepsis often present with hypothermia rather than fever due to immature thermoregulatory and immune systems. Persistent low body temperature, along with other signs such as lethargy or poor feeding, is a strong indicator of potential sepsis and warrants prompt evaluation and intervention.
D. Coughing: Coughing may indicate a respiratory condition, but isolated coughing is not a sensitive or specific marker for neonatal sepsis. Respiratory distress in combination with systemic signs would be more concerning.
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