A client is diagnosed with a large pulmonary embolism. When explaining what has happened to cause respiratory distress to the client's family, which information will the nurse include?

Thick secretions in your small airways are blocking air from moving into the small air sacs in your lungs

Blood flow through some areas of your lungs is decreased even though you are taking adequate breaths

Large areas of your lungs are getting good blood flow but are not receiving enough air to fill the small air sacs

Oxygen transfer into the blood is slow because of thick membranes between the small air sacs and the lung circulation

Answer and Explanation

The Correct Answer is B

Choice A reason: Thick secretions blocking airways are characteristic of conditions like chronic obstructive pulmonary disease or pneumonia, not pulmonary embolism. In pulmonary embolism, a clot obstructs pulmonary arteries, reducing blood flow to alveoli, not airflow. This leads to ventilation-perfusion mismatch, causing hypoxemia despite adequate breathing, making this explanation incorrect.

Choice B reason: A pulmonary embolism blocks pulmonary arteries, reducing blood flow to certain lung regions despite normal ventilation. This creates a ventilation-perfusion mismatch, where alveoli are ventilated but not perfused, leading to hypoxemia and respiratory distress. This is the primary mechanism of pulmonary embolism, making it the correct explanation for the family.

Choice C reason: This option suggests adequate blood flow but inadequate air to alveoli, which describes conditions like airway obstruction or atelectasis, not pulmonary embolism. In pulmonary embolism, the issue is reduced blood flow due to arterial obstruction, not insufficient air reaching alveoli, as breathing remains adequate, making this incorrect.

Choice D reason: Thickened alveolar-capillary membranes, impairing oxygen diffusion, occur in conditions like pulmonary fibrosis or edema, not pulmonary embolism. In pulmonary embolism, the primary issue is vascular obstruction, not membrane thickness, leading to reduced perfusion and hypoxemia despite normal alveolar structure, rendering this explanation scientifically inaccurate.

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Correct Answer is A

Explanation

Choice A reason: Deep partial- and full-thickness burns to the neck and chest risk airway edema due to thermal injury, leading to obstruction. The resuscitation phase prioritizes the ABCDE approach, with airway as the first concern. Ensuring a patent airway via assessment or intubation prevents respiratory arrest, making this the most critical intervention.

Choice B reason: Pain medication is essential for burn patients due to severe pain from nerve exposure, but it is not the priority in the resuscitation phase. The ABCDE approach places airway and breathing above pain management. Airway compromise from neck burns can be fatal, making pain control secondary to airway patency.

Choice C reason: Inserting an indwelling urinary catheter monitors urine output, critical for assessing fluid resuscitation in burns. However, in the ABCDE approach, airway takes precedence over circulation monitoring. Neck and chest burns risk rapid airway obstruction, making catheter insertion a secondary intervention after ensuring airway and breathing are stable.

Choice D reason: Fluid resuscitation is vital in burns to correct hypovolemia from plasma leakage, but it follows airway and breathing in the ABCDE approach. Neck and chest burns pose an immediate airway threat due to edema, requiring prioritization of airway patency to prevent respiratory failure before addressing circulatory needs.

A. Administer IV mannitol B. Elevate the head of the bed to 30 degrees C. Initiate seizure prophylaxis D. Increase sedation

Correct Answer is B

Explanation

Choice A reason: IV mannitol reduces intracranial pressure by drawing fluid from brain tissue, but it requires a provider’s order and time to act. ICP of 22 mm Hg is elevated, and elevating the head of the bed is a non-invasive, immediate intervention to promote venous drainage, making it the priority action.

Choice B reason: An ICP of 22 mm Hg indicates elevated intracranial pressure, risking brain herniation. Elevating the head of the bed to 30 degrees promotes cerebral venous drainage, reducing ICP immediately. This non-invasive intervention aligns with the ABCDE approach’s focus on preventing neurological deterioration, making it the first action in traumatic brain injury management.

Choice C reason: Seizure prophylaxis prevents complications in traumatic brain injury but does not directly address elevated ICP (22 mm Hg). Seizures increase ICP further, but immediate pressure reduction is critical to prevent herniation. Head elevation is a faster, non-invasive intervention, making seizure prophylaxis secondary in this acute scenario.

Choice D reason: Increasing sedation controls agitation, which can raise ICP, but it risks respiratory depression and requires careful monitoring. ICP of 22 mm Hg needs immediate reduction, and head elevation promotes venous drainage without delay. Sedation is a supportive measure, making it less urgent than positioning to lower ICP.

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A client is diagnosed with a large pulmonary embolism. When explaining what has happened to cause respiratory distress to the client's family, which information will the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his neck, chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury?

Correct Answer is A

Explanation

A nurse is caring for a client with a traumatic brain injury in the ICU. The client’s intracranial pressure (ICP) is 22 mm Hg. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

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