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.

Dyspnea.

Dry cough.

Tachycardia.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Dyspnea.

Choice B rationale: Dyspnea, or difficulty breathing, is a potential indication of a recurrent pulmonary embolism and should be reported immediately. Early detection and intervention are crucial to prevent life-threatening complications.

Choice A rationale: Hypotension may be a concerning finding in postoperative clients, but it is not the priority for a client with a history of pulmonary embolism. Hypotension could be related to various factors like bleeding or anesthesia effects.

Choice C rationale: Dry cough may occur as a result of irritation or inflammation in the airway due to the surgical procedure or anesthesia. Although it should be monitored, it is not the highest priority in this situation.

Choice D rationale: Tachycardia can be a common postoperative finding due to pain, anxiety, or other factors. Although it should be monitored and addressed, it is not the most critical concern in this case. Dyspnea is more closely related to a possible pulmonary embolism and should be reported promptly.

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Correct Answer is C

Explanation

Choice A rationale:

Recording the client's progress in the nurses' notes is important for documentation but does not directly promote communication among staff caring for the client. It is essential for the continuity of care and legal documentation, but it does not facilitate active communication between team members.

Choice B rationale:

Posting swallowing precautions at the head of the client's bed is essential for the client's safety, especially considering the risk of aspiration following a stroke. While it ensures the staff is aware of the precautions, it does not directly promote communication among the staff members.

Choice C rationale:

Having interdisciplinary team meetings for the client on a regular basis is the best choice as it promotes communication among the staff caring for the client. Interdisciplinary team meetings allow healthcare professionals from various disciplines, such as nurses, therapists, and doctors, to collaborate, share information, and discuss the best approach to care for the client. This approach ensures comprehensive and coordinated care, addressing both the client's medical and communication needs.

Choice D rationale:

Noting changes in the treatment plan in the client's medical record is crucial for documentation and continuity of care but does not actively promote real-time communication among the staff members. While it is essential for keeping the medical record updated, it does not facilitate immediate communication and collaboration between healthcare professionals.

A. Complete an incident report. B. Notify the client's provider. C. Document the fall in the client's medical record. D. Measure the client's vital signs.

Correct Answer is D

Explanation

The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.

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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?

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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?