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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Correct Answer is D

Explanation

Choice A Reason:
Bright lighting can be overwhelming for clients experiencing perceptual alterations. While regular checks on the client's mental status are important, excessive brightness can exacerbate sensory overload. The goal is to create an environment that is calming and reduces sensory stimuli to manageable levels.

Choice B Reason:
Keeping the lights dim may help to soothe some clients, but continuous noise from a radio can contribute to sensory overload. It's crucial to tailor the environment to the individual needs of the client, which often means providing a quiet space with minimal auditory distractions.

Choice C Reason:
Having the client sit by the nurse's desk may provide necessary supervision, but it can also expose the client to high levels of activity and noise, which can be disorienting. Rest periods with the television on can be distracting and may not offer the tranquil environment needed for a client with perceptual alterations.

Choice D Reason:
Providing a well-lit room without glare or shadows and limiting noise is the most appropriate environmental change for a client with perceptual alterations. This approach helps to reduce the risk of misperceptions and hallucinations, which can be triggered by shadows and glare. A quiet and well-lit environment supports better sensory processing and helps to maintain orientation.

A. Take vitamin B6 daily to prevent peripheral neuropathy. B. Your urine and tears may turn orange. C. Arrange for a hearing exam to monitor for hearing loss. D. Wear sunscreen to prevent photosensitivity reactions.

Correct Answer is A

Explanation

Choice A reason:
Isoniazid, an antitubercular medication, can cause peripheral neuropathy, a form of nerve damage characterized by numbness, tingling, or pain, particularly in the hands and feet. This side effect is due to the drug's interference with the normal metabolism of vitamin B6 (pyridoxine). Supplementation with vitamin B6 is recommended to prevent this complication. The normal daily recommended intake for vitamin B6 in adults ranges from 1.3 to 1.7 mg.

Choice B reason:
While it is true that isoniazid can cause discoloration of bodily fluids, turning urine and tears orange, this is not a harmful side effect and does not require intervention. It is, however, important to inform the client of this possibility to prevent alarm.

Choice C reason:
There is no evidence to suggest that routine hearing exams are necessary for clients taking isoniazid unless they have pre-existing hearing conditions or are taking other medications known to affect hearing. Therefore, this is not a standard part of the teaching plan for clients on isoniazid.

Choice D reason:
Photosensitivity reactions are not commonly associated with isoniazid use. While wearing sunscreen is generally good advice for skin protection, it is not specifically related to the administration of isoniazid and thus would not be the primary information to include in the teaching plan.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What environmental changes should the nurse make for a client who is experiencing perceptual alterations?

Correct Answer is D

Explanation

A client is receiving isoniazid after being diagnosed with tuberculosis. Which information should the nurse include in the client's teaching plan?

Correct Answer is A

Explanation

A client is diagnosed with active tuberculosis and is started on medications. The nurse is aware that which parameter best indicates that the prescribed therapy has been effective? The client has:

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