A nurse is assessing a 24-year-old female client in the emergency department (ED).

Complete the following sentence by using the list of options. The nurse should first obtain ABGs followed by:
________

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A"}

Choice A rationale: Initiating anticoagulant therapy with heparin is the priority after confirming or strongly suspecting a pulmonary embolism (PE). The elevated D-dimer (>0.4 mcg/mL; client’s = 1.0 mcg/mL), signs of deep vein thrombosis (calf swelling, tenderness), sudden dyspnea, and chest pain with hypoxia (O2 sat 90%) all support PE. Heparin prevents further clot propagation and reduces risk of additional emboli reaching the pulmonary circulation. Early anticoagulation significantly reduces mortality and prevents long-term complications like pulmonary hypertension.

Choice B rationale: Administering oral analgesics does not address the underlying cause of the client’s symptoms, which is likely thromboembolism. Pain in this case is secondary to inflammation and ischemia related to embolism. While symptom relief is important, masking pain without addressing perfusion issues delays definitive care. Also, oral administration may be inappropriate in hemodynamically unstable or hypoxic patients due to risk of aspiration or delayed onset. This action is supportive, not emergent, and should not precede anticoagulation.

Choice C rationale: A chest X-ray may help rule out differential diagnoses like pneumonia or pneumothorax, but it is often nonspecific in pulmonary embolism. Typical findings such as atelectasis or pleural effusion lack sensitivity and may delay more appropriate imaging such as CT pulmonary angiography. Furthermore, the patient is symptomatic and hypoxic, requiring immediate stabilization and anticoagulation, not diagnostic delay. Chest X-ray may be useful later but is not prioritized before life-saving interventions like anticoagulation.

Choice D rationale: Increasing oxygen flow rate may temporarily improve oxygen saturation, but it does not address the embolic cause of the hypoxia. Pulmonary embolism leads to a ventilation-perfusion mismatch that oxygen alone cannot correct. Oxygen supplementation is supportive and should be continued, but anticoagulation directly targets the pathophysiology. Treating only the symptom (hypoxia) without preventing further thrombus migration risks clinical deterioration. Therefore, this is a secondary rather than a primary action.

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Correct Answer is A

Explanation

Choice A rationale

Sun exposure, specifically ultraviolet (UV) radiation, is a well-known trigger for exacerbations in systemic lupus erythematosus (SLE). UV light can induce apoptosis of keratinocytes, leading to the release of nuclear antigens. These antigens can then stimulate the immune system in susceptible individuals, precipitating or worsening disease activity, including skin rashes, fatigue, and organ inflammation. Therefore, sunbathing is contraindicated.

Choice B rationale

Hair dyes and relaxers contain chemicals that can irritate the scalp and potentially trigger a cutaneous lupus flare or hair loss in individuals with SLE, especially during periods of active disease. Avoiding these irritants during remission helps minimize the risk of exacerbations, maintaining scalp health and preventing potential immune system activation which could lead to a flare.

Choice C rationale

Fever in a client with SLE can indicate an active inflammatory process, infection, or a disease flare. The immune dysregulation in SLE makes these clients more susceptible to infections and inflammatory responses. Prompt reporting allows for timely evaluation to differentiate between infection and a lupus flare, enabling appropriate and rapid intervention to prevent complications.

Choice D rationale

Adherence to prescribed medications, even when symptoms improve, is crucial in managing chronic autoimmune diseases like SLE. Medications, often immunosuppressants or anti-inflammatories, work to control disease activity, prevent organ damage, and maintain remission. Discontinuing medication prematurely can lead to a rebound of symptoms, disease flares, and irreversible organ damage.

A. Grilled chicken, white rice, sliced peaches. B. Fried shrimp, cauliflower, yogurt with granola. C. Grilled salmon, brown rice, broccoli. D. Spaghetti with tomato sauce, meatballs, and garlic bread.

Correct Answer is A

Explanation

Choice A rationale

Grilled chicken and white rice are low in fat and fiber, making them easily digestible and less likely to exacerbate diarrhea in an immunocompromised client with AIDS. Peaches, when peeled, offer easily digestible carbohydrates and some electrolytes, aiding in rehydration without increasing gastrointestinal motility, which is crucial for nutrient absorption in clients with compromised gut integrity.

Choice B rationale

Fried shrimp is high in fat, which can stimulate gastrointestinal motility and worsen diarrhea, leading to malabsorption. Cauliflower is a cruciferous vegetable high in insoluble fiber, which can irritate the bowel. Granola contains nuts and seeds, which are high in fiber and can be difficult to digest, potentially aggravating diarrhea.

Choice C rationale

Grilled salmon, while a healthy protein, is higher in fat than chicken, potentially contributing to gastrointestinal upset. Brown rice is a whole grain high in fiber, which can increase stool bulk and frequency. Broccoli is a high-fiber vegetable that can cause gas and bloating, worsening diarrheal symptoms.

Choice D rationale

Spaghetti with tomato sauce can be acidic and may irritate a sensitive bowel. Meatballs can be high in fat, which may worsen diarrhea. Garlic bread often contains fats and spices that can further irritate the gastrointestinal tract, leading to increased fluid loss.

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A nurse is assessing a 24-year-old female client in the emergency department (ED). Complete the following sentence by using the list of options. The nurse should first obtain ABGs followed by:________

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is assessing a 24-year-old female client in the emergency department (ED).

Complete the following sentence by using the list of options. The nurse should first obtain ABGs followed by:
________