A nurse is caring for a client diagnosed with deep vein thrombosis who suddenly complains of severe chest pain, shortness of breath, and is extremely anxious. The nurse suspects that the client may have developed a pulmonary embolism. Which intervention should the nurse perform first?

Perform a 12-lead electrocardiogram and call a rapid response.

Elevate the head of the bed and apply 2 liters of nasal oxygen.

Instruct the client to remain calm and administer lorazepam.

Increase the intravenous rate from 80 mL to 100 mL/hr.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Performing a 12-lead electrocardiogram and calling a rapid response team are important steps when a pulmonary embolism is suspected. However, these actions are not the immediate first-line interventions. The priority is to address the client's oxygenation needs to prevent further hypoxemia and potential cardiac arrest.

Choice B reason:
Elevating the head of the bed and applying 2 liters of nasal oxygen is the most appropriate initial intervention. This position helps improve the expansion of the lungs and oxygenation, while the supplemental oxygen can help alleviate hypoxemia, which is critical in the management of a pulmonary embolism.

Choice C reason:
While ensuring the client remains calm is beneficial, administering lorazepam is not the first-line treatment for a suspected pulmonary embolism. Lorazepam may be used for its anxiolytic effects, but it does not address the immediate life-threatening issues of oxygenation and potential hemodynamic instability.

Choice D reason:
Increasing the intravenous rate may be considered to maintain adequate hydration and venous return, but it is not the first intervention for a suspected pulmonary embolism. The priority is to stabilize the client's respiratory status and oxygenation.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason
Providing a quiet atmosphere for undisturbed sleep is beneficial for all patients, especially those recovering from illness. However, it does not directly address the issue of activity intolerance. Adequate rest is important, but the primary concern with activity intolerance is managing energy levels during waking hours to improve the patient's ability to engage in activities.

Choice B Reason
Clustering activities in the morning may seem like a good strategy when the patient is well-rested. However, this could lead to rapid depletion of energy reserves and exacerbate activity intolerance. It is more effective to spread activities throughout the day to manage energy levels better.

Choice C Reason
Identifying ways to conserve energy is a key intervention for managing activity intolerance. This can include teaching the patient energy-conservation techniques, such as sitting while showering or dressing, taking frequent breaks, and prioritizing tasks. This approach helps patients with folic acid deficiency anemia to participate in activities without excessive fatigue.

Choice D Reason
While nutrition is important in the management of anemia, recommending small frequent iron-rich meals does not directly address activity intolerance. Folic acid deficiency anemia requires dietary intake of folate-rich foods or supplements. Iron is important, but the focus for folic acid deficiency should be on folate.

A. St. John's Wort B. Black Cohosh C. Peppermint D. Echinacea

Correct Answer is A

Explanation

Choice A Reason:
St. John's Wort is a well-known herbal remedy that has been used for centuries to treat various ailments, including depression. It is believed to work by increasing the levels of neurotransmitters in the brain, such as serotonin, which can help improve mood and alleviate depressive symptoms. Clinical studies have shown that St. John's Wort can be effective for mild to moderate depression.

Choice B Reason:
Black Cohosh is primarily used to relieve symptoms associated with menopause, such as hot flashes and night sweats. While it may have some mood-stabilizing effects, there is insufficient evidence to support its use as a primary treatment for depression.

Choice C Reason:
Peppermint is commonly used for its soothing properties to aid digestion and reduce headaches. However, it is not typically used as a treatment for depression, and there is no substantial evidence to suggest it would be effective for this purpose.

Choice D Reason:
Echinacea is best known for its potential to boost the immune system and reduce symptoms of colds and other infections. It is not recognized as a treatment for depression, and there is no significant research to support its use in this context.

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A nurse is caring for a client diagnosed with deep vein thrombosis who suddenly complains of severe chest pain, shortness of breath, and is extremely anxious. The nurse suspects that the client may have developed a pulmonary embolism. Which intervention should the nurse perform first?

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A nurse is caring for a client diagnosed with deep vein thrombosis who suddenly complains of severe chest pain, shortness of breath, and is extremely anxious. The nurse suspects that the client may have developed a pulmonary embolism. Which intervention should the nurse perform first?