A nurse is caring for a client diagnosed with pulmonary embolism.
Which new-onset assessment finding should a nurse expect in a client diagnosed with a pulmonary embolism?

Choice A rationale: Initiating anticoagulant therapy with heparin is the priority after confirming or strongly suspecting a pulmonary embolism (PE). The elevated D-dimer (>0.4 mcg/mL; client’s = 1.0 mcg/mL), signs of deep vein thrombosis (calf swelling, tenderness), sudden dyspnea, and chest pain with hypoxia (O2 sat 90%) all support PE. Heparin prevents further clot propagation and reduces risk of additional emboli reaching the pulmonary circulation. Early anticoagulation significantly reduces mortality and prevents long-term complications like pulmonary hypertension.

Choice B rationale: Administering oral analgesics does not address the underlying cause of the client’s symptoms, which is likely thromboembolism. Pain in this case is secondary to inflammation and ischemia related to embolism. While symptom relief is important, masking pain without addressing perfusion issues delays definitive care. Also, oral administration may be inappropriate in hemodynamically unstable or hypoxic patients due to risk of aspiration or delayed onset. This action is supportive, not emergent, and should not precede anticoagulation.

Choice C rationale: A chest X-ray may help rule out differential diagnoses like pneumonia or pneumothorax, but it is often nonspecific in pulmonary embolism. Typical findings such as atelectasis or pleural effusion lack sensitivity and may delay more appropriate imaging such as CT pulmonary angiography. Furthermore, the patient is symptomatic and hypoxic, requiring immediate stabilization and anticoagulation, not diagnostic delay. Chest X-ray may be useful later but is not prioritized before life-saving interventions like anticoagulation.

Choice D rationale: Increasing oxygen flow rate may temporarily improve oxygen saturation, but it does not address the embolic cause of the hypoxia. Pulmonary embolism leads to a ventilation-perfusion mismatch that oxygen alone cannot correct. Oxygen supplementation is supportive and should be continued, but anticoagulation directly targets the pathophysiology. Treating only the symptom (hypoxia) without preventing further thrombus migration risks clinical deterioration. Therefore, this is a secondary rather than a primary action.

Choice A rationale

While responding to ventilator alarms is crucial for patient safety, it is a general responsibility when a client is on a mechanical ventilator. For a client receiving a neuromuscular blockade agent, the absolute inability to move or communicate makes other specific interventions, such as placing the call bell, a higher priority due to the unique vulnerability.

Choice B rationale

Encouraging the client to take spontaneous breaths is inappropriate and potentially dangerous for a client receiving a neuromuscular blockade agent. These agents cause complete paralysis of voluntary muscles, including the diaphragm. Attempting spontaneous breaths is impossible and could lead to severe respiratory distress if the client were not fully paralyzed or the medication was wearing off.

Choice C rationale

Placing the call bell within reach is the highest priority for a client receiving a neuromuscular blockade agent. These agents induce complete paralysis without affecting consciousness or sensation. Therefore, the client is fully aware but unable to move or speak. The call bell provides the only means for them to communicate distress or needs, ensuring their safety and comfort.

Choice D rationale

Reporting the absence of spontaneous respirations is expected when a client is receiving a neuromuscular blockade agent. The purpose of these medications is to paralyze respiratory muscles to facilitate mechanical ventilation. Therefore, the absence of spontaneous respirations is an anticipated and desired effect, not an abnormal finding to be reported as a concern.