A nurse is caring for a client newly diagnosed with a pulmonary embolism (PE). Which of the following is the initial assessment finding in the client diagnosed with PE?

Dyspnea and anxiety.

Altered level of consciousness.

Wheezing in lung bases.

Increased pulse and respiratory rate.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The initial assessment finding in a client diagnosed with a pulmonary embolism (PE) is typically dyspnea and anxiety. This is because a PE can block blood flow in the lungs, leading to difficulty breathing (dyspnea). The sudden onset of this symptom can cause significant anxiety in the patient.
Choice B rationale
An altered level of consciousness is not typically an initial finding in PE. While severe cases can lead to decreased oxygen levels in the blood, causing confusion or loss of consciousness, these are not usually initial symptoms.
Choice C rationale
Wheezing in lung bases is not a typical initial finding in PE. Wheezing is more commonly associated with conditions that cause narrowing of the airways, such as asthma or COPD12.
Choice D rationale
While an increased pulse and respiratory rate can occur in PE due to the body’s attempt to compensate for decreased oxygen in the blood, they are not the most specific initial findings. Dyspnea and anxiety are more characteristic initial symptoms of PE12.

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Correct Answer is B

Explanation

Choice A rationale
While it is important to monitor oxygen use to prevent hypoxia and hypercapnia, taking breaks from oxygen use is not typically recommended for clients with COPD. These clients often require supplemental oxygen to maintain adequate oxygen saturation.
Choice B rationale
Maintaining a low flow rate of oxygen is crucial in clients with COPD. These clients are often “CO2 retainers,” and administering a high concentration of oxygen can suppress their respiratory drive, leading to further CO2 retention and respiratory distress.
Choice C rationale
While it is important to assess for signs of skin breakdown in clients receiving oxygen therapy, this is not the priority when administering nasal oxygen to a client with COPD38.
Choice D rationale
Clients should not adjust their oxygen flow rate without medical supervision. Increasing the oxygen flow rate can lead to hyperoxia, which can be harmful, especially in clients with COPD who are CO2 retainers.

A. Muffled heart sounds. B. Sudden hemoptysis. C. Absent breath sounds on the affected side. D. Declining respiratory rate.

Correct Answer is C

Explanation

Choice A rationale
Muffled heart sounds are not a typical sign of pneumothorax. They are more commonly associated with conditions such as pericardial effusion or cardiac tamponade.
Choice B rationale
Sudden hemoptysis, or coughing up blood, is not a typical sign of pneumothorax. It is more commonly associated with conditions such as pulmonary embolism or lung cancer.
Choice C rationale
Absent breath sounds on the affected side is a typical sign of pneumothorax. When air enters the pleural space and causes the lung to collapse, breath sounds may be absent or significantly decreased on the affected side.
Choice D rationale
A declining respiratory rate is not a typical sign of pneumothorax. In fact, a rapid respiratory rate (tachypnea) is more commonly observed in pneumothorax due to the body’s attempt to compensate for the decreased lung capacity.

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A nurse is caring for a client newly diagnosed with a pulmonary embolism (PE). Which of the following is the initial assessment finding in the client diagnosed with PE?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

Correct Answer is B

Explanation

During a central IV line insertion at the bedside, a client reports shortness of breath and becomes tachypneic. Which finding should a nurse suspect indicates the client developed a pneumothorax?

Correct Answer is C

Explanation

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