A client is being treated for a low-risk, stable pulmonary embolism (PE). Which of the following interventions should the nurse prioritize to provide effective management?

Encourage the client to engage in physical therapy to strengthen leg muscles.

Instruct the client to perform deep breathing exercises every hour.

Administer low molecular weight heparin as ordered.

Prepare the client for surgery to remove the embolus.

Answer and Explanation

The Correct Answer is C

A pulmonary embolism (PE) occurs when a blood clot, usually from the deep veins of the legs, travels to and obstructs the pulmonary arteries. Management priorities depend on the severity and stability of the client. In a low-risk, hemodynamically stable PE, the main goal is to prevent clot extension and new thrombus formation while allowing the body to gradually break down the existing clot. Anticoagulation therapy is the cornerstone of treatment in these cases.

Rationale:
A. Encouraging physical therapy to strengthen leg muscles is not a priority in the acute management of a pulmonary embolism. While mobility and rehabilitation are important in long-term prevention of venous thromboembolism, they do not address the existing clot or prevent immediate progression. The priority is anticoagulation to stabilize the condition before initiating strengthening or exercise programs.

B. Instructing the client to perform deep breathing exercises every hour may support lung expansion and oxygenation, but it does not treat the underlying clot or prevent further embolization. Respiratory exercises are supportive care and are secondary to pharmacologic management. They are useful for preventing atelectasis but are not the priority intervention in acute PE treatment.

C. Administering low molecular weight heparin as ordered is the priority intervention because it prevents further clot formation and propagation. Low molecular weight heparin works by inhibiting clotting factors in the coagulation cascade, reducing the risk of additional emboli. In a stable PE, anticoagulation is the first-line therapy to allow the body’s fibrinolytic system to gradually dissolve the existing clot.

D. Preparing the client for surgery to remove the embolus is not indicated in a low-risk, stable pulmonary embolism. Surgical or catheter-directed embolectomy is reserved for massive or life-threatening PE with hemodynamic instability. In stable patients, invasive procedures are unnecessary and expose the client to additional risks without clear benefit.

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Correct Answer is C

Explanation

Tumors are abnormal growths of cells that can be classified as benign or malignant based on their behavior and cellular characteristics. Benign tumors usually grow slowly, remain localized, and have well-differentiated cells that resemble normal tissue. Malignant tumors, on the other hand, show uncontrolled growth, poor differentiation, and the potential to invade nearby tissues and metastasize to distant organs. Understanding these differences is essential for diagnosis, treatment planning, and prognosis.

Rationale:
A. Benign tumors do not spread to distant organs or invade surrounding tissues. They are usually encapsulated, remain confined to their original location, and cause problems mainly by pressure on nearby structures. The ability to invade and metastasize is a defining feature of malignant tumors, not benign growths. Therefore, this statement incorrectly describes benign tumors.

B. Malignant tumors are not typically well-defined or slow-growing. They often have irregular borders, rapid and uncontrolled cell division, and poorly differentiated cells that do not resemble normal tissue. Localized effects with clear boundaries are more characteristic of benign tumors, making this description inaccurate for malignancy.

C. Malignant tumors are marked by rapid growth, abnormal cell structure, and invasion into surrounding tissues. Their cells often show anaplasia, meaning they are poorly differentiated and structurally abnormal compared to healthy cells. They can infiltrate adjacent organs and spread through lymphatic or blood circulation to distant sites, which significantly worsens prognosis.

D. Benign tumors are generally less likely to cause severe systemic symptoms than malignant tumors. Malignant tumors commonly produce systemic effects such as weight loss, fatigue, anemia, and cachexia due to aggressive growth and metastasis. Benign tumors usually cause localized symptoms unless they compress vital organs or produce hormones.

A. 9 B. 10 C. 8 D. 11

Correct Answer is A

Explanation

The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool used to evaluate a client’s level of consciousness, especially after head injury or in critically ill patients. It measures three components: eye opening response, verbal response, and motor response. Each category is assigned a score, and the total score helps determine the severity of neurologic impairment. Accurate calculation is essential for monitoring changes in neurologic status and guiding urgent interventions.

Rationale:
A. A total score of 9 is correct because eye opening to sound scores 3, incomprehensible sounds score 2, and withdrawal from pain scores 4. Adding these values gives a total GCS of 9. This indicates a moderate level of impaired consciousness and requires close neurologic observation for any signs of deterioration.

B. A score of 10 would be incorrect. To achieve a 10, the client would need to demonstrate a higher level of function in one of the three categories, such as using inappropriate words (verbal score of 3) instead of incomprehensible sounds, or localizing to pain (motor score of 5) instead of simple withdrawal. Based on the specific behaviors described in the prompt, a score of 10 overestimates the client's current neurological status.

C. A score of 8 is incorrect because the described responses total more than 8 points. A GCS of 8 is often associated with severe neurologic impairment and may indicate the need for airway protection. In this case, the client’s ability to open eyes to sound and withdraw from pain results in a slightly higher score of 9.

D. A score of 11 is incorrect because it would suggest stronger neurologic responses than those observed. For instance, inappropriate words or obeying commands would raise the total score. Since the verbal response is only incomprehensible sounds and the motor response is limited to withdrawal from pain, the correct score remains 9 rather than 11.

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A client is being treated for a low-risk, stable pulmonary embolism (PE). Which of the following interventions should the nurse prioritize to provide effective management?

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Naxlex Comprehensive Predictor Exams

Which of the following statements best describes the characteristics of malignant tumors compared to benign tumors?

Correct Answer is C

Explanation

A client is assessed using the Glasgow Coma Scale (GCS) and demonstrates the following responses: eyes open to sound, incomprehensible sounds, and withdraws arm from pain. What is the total GCS score for this client?

Correct Answer is A

Explanation

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