A nurse is caring for a client in a clinic.

For each body system below, click to specify the adverse effect that the nurse should include in the teaching. Choose the most likely response for the dropdown(s) in the table below by choosing from the lists of options.

Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	dropdown
Cardiovascular	dropdown
Genitourinary	dropdown
Gastrointestinal	dropdown

Rationale for Correct Choices

• Pulmonary embolism: The client presents with sudden, severe chest pain rated 10/10, tachycardia (122/min), tachypnea (25/min), hypotension (77/45 mm Hg), and hypoxemia (SpO₂ 85%). These findings are consistent with a massive pulmonary embolism causing impaired pulmonary circulation and right-sided cardiac strain. Anxiety and “feels like something bad is going to happen” are also common subjective findings.

• Elevate head of the bed: This positioning improves lung expansion, decreases work of breathing, and enhances oxygenation in a client with impaired pulmonary perfusion.

• Administer anticoagulant: Anticoagulants (e.g., heparin) are first-line treatment to prevent further clot formation and reduce progression of the embolism.

• Respiratory effort: Monitoring work of breathing helps evaluate worsening hypoxia and effectiveness of oxygenation/ventilation support.

• aPTT (pTT): If heparin is used, aPTT is monitored to ensure therapeutic anticoagulation and prevent bleeding complications

Rationale for Incorrect Choices

• Tension pneumothorax: Would present with absent or markedly diminished breath sounds on one side, tracheal deviation, and unilateral chest findings—none are present (lung sounds are vesicular bilaterally and trachea is midline).

• Gastric reflux disease: Would cause burning epigastric pain, often related to meals, not severe hypoxia, hypotension, or tachycardia.

• Palpitations: Would not explain severe hypotension, hypoxemia, or respiratory distress.

• Teach client to avoid fried and spicy foods: Appropriate for GERD, not acute cardiopulmonary collapse.

• Encourage client to consume less caffeine: May reduce palpitations or anxiety symptoms but does not address life-threatening hypoxia and hypotension.

• Assist with chest tube insertion: Indicated for tension pneumothorax, not pulmonary embolism.

• Chest tube drainage: Not applicable because no chest tube is indicated for pulmonary embolism.

• Heart rate irregularity: Not the primary issue; tachycardia is present but rhythm irregularity is not described.

• Epigastric pain: Not consistent with the presenting cardiopulmonary emergency.

Rationale for Correct Choices

• HELLP syndrome: The client presents with a combination of hemolysis, elevated liver enzymes, and low platelets consistent with HELLP syndrome, a severe form of preeclampsia. Supporting findings include hypertension (146/90 mm Hg), protein-related symptoms (edema), neurologic irritability (headache, hyperreflexia, clonus), epigastric pain (liver involvement), and significantly abnormal labs (platelets 98,000/mm³, elevated AST/ALT, elevated LDH, elevated uric acid, and elevated BUN). These findings strongly indicate HELLP syndrome rather than isolated preeclampsia or other obstetric conditions.

• Administer IV labetalol: IV labetalol is an antihypertensive used to manage severe hypertension in preeclampsia/HELLP syndrome. It helps reduce the risk of stroke, placental abruption, and progression to eclampsia by controlling blood pressure safely in pregnancy.

• Administer platelets: The client has thrombocytopenia (platelets 98,000/mm³), increasing the risk of bleeding, especially during delivery or potential invasive procedures. Platelet administration may be required to stabilize the client and reduce hemorrhagic risk.

• Creatinine level: HELLP syndrome can progress to acute kidney injury due to endothelial dysfunction and decreased renal perfusion. Monitoring creatinine helps assess renal involvement and disease progression.

• Postictal mental status: The client is at high risk for progression to eclampsia (seizures). Monitoring postictal mental status helps evaluate neurologic recovery and detect seizure activity early.

Rationale for Incorrect Choices

• Eclampsia: Although the client has neurologic symptoms (headache, hyperreflexia, clonus), there is no evidence of active seizures. The defining feature of eclampsia is seizure activity, which is not present here.

• Appendicitis: Epigastric pain may occur in preeclampsia/HELLP due to liver involvement, not localized right lower quadrant pain or signs of acute abdominal infection.

• Preterm labor: There are no uterine contractions, cervical changes, or reports of back pain or fluid leakage. Fetal movement is present and reassuring.

• Perform a nonstress test: While fetal assessment is important, this is not the priority over maternal stabilization in HELLP syndrome.

• Obtain MRI of abdomen: Imaging is not indicated for diagnosing HELLP syndrome and would delay urgent management.

• Administer subcutaneous terbutaline: This is used to stop preterm labor, which is not present in this case.

• Blood glucose level: Not directly relevant to HELLP syndrome management or progression.

• Presence of pain in the lower quadrant: This would be more relevant for appendicitis, not HELLP syndrome (which causes epigastric/right upper quadrant pain).

• Fetal fibronectin: Used to assess risk of preterm labor, which is not indicated here.