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
While maintaining a stable blood pressure is important for a client with hypertension, furosemide is primarily a diuretic, and its therapeutic effect is to reduce fluid overload, not directly to stabilize blood pressure. Therefore, this finding alone does not best indicate the therapeutic effect of furosemide.

Choice B Reason
Clear lungs upon auscultation suggest an improvement in pulmonary edema, which can be associated with fluid overload in conditions such as heart failure. However, for a client with peripheral edema, the primary therapeutic goal of furosemide is to reduce the excess fluid in the extremities, not just the lungs.

Choice C Reason
A decrease in serum potassium is a known side effect of furosemide due to its action on the kidneys, leading to increased excretion of potassium. While it's important to monitor for hypokalemia, a decrease in potassium does not directly indicate the therapeutic effect of reducing edema.

Choice D Reason
An increase in urine output from 30 mL per hour to 100 mL per hour is a direct indication that furosemide is achieving its therapeutic effect. Furosemide is a loop diuretic that increases urine production to help the body eliminate excess fluid, thereby reducing edema associated with conditions like hypertension.

A. Obesity B. The client drinks several glasses of beer every night. C. Use of a thiazide diuretic. D. Depression. E. Hypertension.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:
Obesity is a significant risk factor for gout. It can lead to increased production and decreased excretion of uric acid, which in turn can cause gout attacks. The normal body mass index (BMI) range is 18.5 to 24.9, and a BMI of 30 or above is considered obese.

Choice B reason:
Regular consumption of beer can increase the risk of gout. Beer is high in purines, which the body breaks down into uric acid, and alcohol can reduce the excretion of uric acid by the kidneys. Moderation in alcohol consumption is advised, with the recommendation being up to one drink per day for women and up to two drinks per day for men.

Choice C reason:
Thiazide diuretics are associated with an increased risk of gout. They can decrease the kidney's ability to remove uric acid from the body, leading to its accumulation. When prescribing thiazide diuretics, healthcare providers often monitor uric acid levels and consider alternative medications if the patient has a history of gout.

Choice D reason:
Depression is not directly identified as a risk factor for developing gout. However, some lifestyle factors associated with depression, such as poor diet and inactivity, could indirectly increase the risk.

Choice E reason:
Hypertension is a known risk factor for gout. High blood pressure can impair kidney function, which is responsible for excreting uric acid, thus leading to hyperuricemia and gout. The normal range for blood pressure is considered to be below 120/80 mmHg.

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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

After administering furosemide 20 mg PO to a client diagnosed with hypertension and peripheral edema, which finding would best indicate that the therapeutic effect of the medication has been achieved?

Correct Answer is D

Explanation

A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply)

Correct Answer is ["A","B","C","E"]

Explanation

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