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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
A PTT of 70 seconds (control 25-40) indicates that the patient’s blood is taking longer than normal to clot, which could increase the risk of bleeding. This could be a sign of excessive anticoagulation from the Heparin infusion.
Choice B rationale
Ecchymosis at the venipuncture site could be a sign of bleeding under the skin, which could indicate that the patient is receiving too much Heparin.
Choice C rationale
Hematuria, or blood in the urine, could be a sign of bleeding in the urinary tract, which could be a side effect of Heparin therapy.
Choice D rationale
If there is an order for Coumadin 2.5 mg to start today, the healthcare provider should be notified. Coumadin and Heparin are both anticoagulants, and using them together could increase the risk of bleeding.
Correct Answer is B
Explanation
Choice A rationale
Establishing a benchmark to identify a standard of performance is a crucial step in any quality improvement process. It provides a reference point against which progress can be measured. However, it does not directly evaluate the effectiveness of the implemented measures.
Choice B rationale
Comparing the number of medication errors before and after the implementation of the measures is the most direct and effective method to evaluate the success of the changes. This method provides quantitative data that can clearly show whether the measures have led to a reduction in medication errors.
Choice C rationale
Conducting a study on the time and cost implications of implementing the change can provide valuable information about the efficiency of the measures. However, it does not directly assess their effectiveness in reducing medication errors.
Choice D rationale
Providing a questionnaire to the staff to quantify their satisfaction with the changes can help to assess the acceptance of the measures among the staff. However, staff satisfaction does not necessarily correlate with the effectiveness of the measures in reducing medication errors.
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