A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
Hypotension
Tachycardia
Dyspnea
Dry cough
The Correct Answer is C
A. Hypotension is a concern but may occur for various reasons and is not as immediately life-threatening as dyspnea.
B. Tachycardia can indicate a problem but is less urgent than respiratory distress.
C. Dyspnea is the priority as it may indicate a recurrence of pulmonary embolism or another life-threatening respiratory issue.
D. A dry cough is a less urgent symptom and does not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Easier to breathe and less short of breath: The client reports improvement in breathing, stating it is easier to breathe and they are less short of breath. This suggests that the respiratory status is improving, which is a key indicator of progress.
Lung sounds still diminished with crackles, but no wheezes detected: While lung sounds are still diminished and crackles remain, the absence of wheezes indicates that the client’s condition is stabilizing. Wheezing would be concerning for bronchospasm or worsening respiratory distress, so the absence of this finding is a positive development.
Oxygen saturation 92%: The client’s oxygen saturation has improved from 88% on room air (Day 1) to 92% on 1 L/min of oxygen. Although still slightly below the target of 94%–98%, this improvement is a sign that oxygenation is improving with the current treatment.
Pleuritic chest pain reduced to 3/10: The client's report of pleuritic chest pain has decreased from 6/10 to 3/10. This reduction in pain indicates a positive response to treatment and the improvement of the underlying infection.
Increased oral intake (drinking 2 L/day): The client is drinking 2 L of fluids per day, which indicates adequate hydration and may help with recovery, particularly in the context of respiratory and infection management.
Normal urine output (200 mL of clear yellow urine): The client’s urine output appears adequate, and the urine is clear and yellow, which suggests proper hydration and normal renal function, supporting overall recovery.
Correct Answer is B
Explanation
A. Flumazenil is used for benzodiazepine overdose, not opioid overdose.
B. Naloxone is the antidote for opioid overdose and is indicated here due to the low respiratory rate and recent administration of hydromorphone.
C. Acetylcysteine is used for acetaminophen overdose, not opioids.
D. Protamine is used to reverse heparin, not opioids.
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