A client with chronic stable angina reports a new onset of shortness of breath at rest. The nurse obtains vital signs and records a heart rate of 168 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 124/76 mm Hg. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Rhythm of apical heart rate.

Volume of pedal pulses.

Degree of skin elasticity.

Length of capillary refill.

Answer and Explanation

The Correct Answer is A

A. Rhythm of apical heart rate: Assessing the rhythm of the apical heart rate is most important, especially with a rate of 168 bpm. This could indicate a tachydysrhythmia (e.g., atrial fibrillation with rapid ventricular response or supraventricular tachycardia) contributing to the new shortness of breath.

B. Volume of pedal pulses: Although assessing peripheral perfusion is important, pedal pulses are not the priority in the context of a dangerously high heart rate and new respiratory symptoms.

C. Degree of skin elasticity: Skin turgor evaluates hydration but is not directly relevant in the setting of acute cardiac symptoms. It does not provide timely data to explain the new-onset shortness of breath or tachycardia.

D. Length of capillary refill: Capillary refill is a general indicator of perfusion, but it is less specific and immediate compared to assessing the heart rhythm. It may be slightly delayed in this case but won’t clarify the underlying cardiac issue.

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Correct Answer is []

Explanation

Pulmonary embolism: The client’s recent orthopedic surgery, delayed mobility, obesity, and elevated D-dimer place her at high risk for PE. Her symptoms pleuritic chest pain, dyspnea, low oxygen saturation, anxiety, and sinus tachycardia are hallmark findings of PE.
Elevate the head of the bed and administer oxygen by mask or nasal cannula: Supporting oxygenation is the immediate priority in a suspected PE. Elevating the head of the bed improves ventilation, while oxygen therapy helps correct hypoxemia until more definitive treatment begins.
Prepare to initiate anticoagulation therapy: Anticoagulation is the frontline treatment for pulmonary embolism to prevent clot progression and recurrence. It is initiated as soon as PE is suspected, even before imaging confirms the diagnosis.
Arterial blood gas: ABG will help assess the extent of oxygenation impairment and respiratory compromise caused by the embolism. Hypoxemia and respiratory alkalosis are commonly seen in acute PE.
Pain score monitoring allows evaluation of symptom progression and the effectiveness of supportive measures. Pain may persist or worsen with increased clot burden, making regular assessment necessary.
Myocardial infarction: While chest pain and tachycardia can suggest MI, the troponin levels are normal, the ECG only shows sinus tachycardia (no ST changes), and the pain is pleuritic and positional atypical of MI. The elevated D-dimer and recent surgery point more strongly toward PE.
Anxiety: Although the client is anxious and dyspneic, these are more likely symptoms of the underlying cardiopulmonary issue rather than the primary diagnosis. Anxiety alone would not cause hypoxia, crackles, and elevated D-dimer.
Sepsis: Sepsis might present with hypotension and elevated WBC, but this client’s vitals and CBC are within range. There is no evidence of infection, fever, or systemic inflammatory response that would indicate sepsis over PE.
Instruct client to bear down to decrease heart rate: This vagal maneuver (Valsalva) is appropriate for supraventricular tachycardia, not for sinus tachycardia due to hypoxia. It could worsen symptoms in a client with compromised oxygenation like PE.
Prepare client for drawing blood cultures: Blood cultures are relevant when infection or sepsis is suspected. The client shows no signs of infection (e.g., fever, chills, elevated WBC), so this action does not address the most likely diagnosis.
Place client in Trendelenburg position: Positioning such as Trendelenburg is not appropriate for PE and can worsen respiratory function. Instead, upright positioning helps improve lung expansion and oxygenation.
Skin: Skin color and temperature can indicate perfusion but are nonspecific. They won't directly measure improvement or deterioration in a client with PE, especially once oxygen therapy is initiated.
Clotting factors: While clotting studies are monitored when administering anticoagulants, they are not immediate indicators of PE progression or treatment response. They are important later but not primary for initial monitoring.
Cardiac enzymes: These are essential in diagnosing myocardial infarction, not PE. Since troponin is within normal limits, monitoring enzymes will not provide relevant information in this context.

Correct Answer is []

Explanation

Pulmonary embolism (PE): The client presents with sudden-onset chest pain, dyspnea, hypoxia (SpO₂ 89% on room air), tachypnea, tachycardia, and cyanosis. These are classic signs of a pulmonary embolism, especially following trauma or immobility, such as after a lower extremity fracture and recent surgery.
Start continuous cardiorespiratory monitoring: Given the client's compromised respiratory status and cardiac involvement, continuous monitoring is needed to detect worsening hypoxia, dysrhythmias, or hemodynamic instability associated with PE.
Administer heparin subcutaneous: Anticoagulation with heparin is the standard first-line treatment for PE. It prevents further clot formation and reduces the risk of clot propagation, helping stabilize the client while further evaluation continues.
Oxygen saturation: Monitoring SpO₂ helps assess the client's respiratory function and the effectiveness of oxygen therapy or anticoagulation. PE impairs gas exchange, so O₂ saturation is a key indicator of clinical progress.
Cardiac markers: PE can strain the right side of the heart, leading to ischemia. Monitoring cardiac markers helps detect myocardial stress or injury secondary to increased pulmonary vascular resistance.
Deep vein thrombosis (DVT): While DVT is a risk factor, the client’s acute chest symptoms and hypoxia suggest the clot has embolized to the lungs, indicating PE rather than isolated DVT.
Myocardial infarct: Although chest pain and increased cardiac workload are seen in both MI and PE, the absence of cardiac history, coupled with low oxygen saturation and recent surgery, makes PE more likely than MI.
Adult respiratory distress syndrome (ARDS): ARDS involves diffuse alveolar damage and is usually a complication of sepsis or trauma. This client’s symptoms developed suddenly and asymmetrically, favoring PE over ARDS.
Prepare client for mechanical ventilation: Mechanical ventilation may be needed if the client deteriorates, but his current oxygen saturation and respiratory rate do not yet require intubation.
Get consent signed for angioplasty: Angioplasty is used for coronary artery occlusion (e.g., in MI), not PE. The client's presentation is not consistent with myocardial infarction requiring catheter intervention.
Arrange for surgeon to establish artificial airway via tracheostomy: A tracheostomy is not an emergency intervention for acute hypoxia due to PE. Airway is currently patent and oxygenation, while impaired, is being monitored non-invasively.
Kidney function: While important for general monitoring, it is not the most relevant parameter in assessing PE progression unless complications arise from anticoagulation therapy.
Presence of petechiae of the thorax: Petechiae is a sign more specific to fat embolism syndrome, particularly after long bone fractures. The client has a lower leg fracture with chest pain but no evidence of petechiae.
Ventilator settings: The client is not mechanically ventilated, so ventilator settings are not relevant at this point. Monitoring focuses on spontaneous respiratory function and perfusion.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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