A nurse is caring for a client who develops a pulmonary embolism: BP 158/68, pulse 98, respirations 26, pulse oximetry 88%. Which of the following interventions should the nurse implement first?
Start an IV infusion of lactated Ringer's
Give morphine IV.
Administer high flow oxygen therapy
Initiate cardiac monitoring
The Correct Answer is C
A. Start an IV infusion of lactated Ringer's: Fluid resuscitation is not the immediate priority in a pulmonary embolism. The first concern is oxygenation. The client’s low oxygen saturation (88%) suggests that oxygen therapy should be the first intervention to stabilize the client.
B. Give morphine IV: Morphine can help manage pain and reduce anxiety, which may aid in improving breathing, but it is not the immediate priority. Administering high-flow oxygen is crucial address the client's hypoxia, which poses a more immediate threat.
C. Administer high flow oxygen therapy: Pulmonary embolism causes impaired gas exchange due to blockage in the pulmonary arteries, leading to low oxygen levels. Administering high-flow oxygen is the first priority to improve oxygenation, stabilize the client, and prevent further complications.
D. Initiate cardiac monitoring: While cardiac monitoring is important in monitoring the client’s condition, especially if there is concern for arrhythmias, the priority is to first stabilize the client’s oxygen levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
To calculate the total intravenous fluids infused in 24 hours for a burn client, use the Parkland formula.
- Calculate Fluid Resuscitation Volume (Parkland Formula)
Convert client's weight from pounds (lb) to kilograms (kg).
Client weight = 147.4 lb / 2.2 lb/kg
= 67 kg.
- Calculate the total fluid volume needed for the first 24 hours using the Parkland formula.
Parkland Formula = 4 mL × client weight (kg) × % TBSA burned
Total fluid volume (24 hrs) = 4 mL × 67 kg × 31.5%
= 8442 mL.
- Calculate Insulin Infusion Volume in 24 hours
Concentration of the insulin solution = 100 units / 100 mL
= 1 unit/mL.
- Calculate the volume of insulin solution infused per hour.
Infusion rate = 5 units/hr
Volume infused per hour (mL/hr) = Desired units/hr / Concentration (units/mL)
= 5 units/hr / 1 unit/mL
= 5 mL/hr.
- Calculate the total volume of insulin solution infused in 24 hours.
Total insulin volume (24 hrs) = Volume infused per hour (mL/hr) × 24 hours
= 5 mL/hr × 24 hours
= 120 mL.
- Calculate Total Intravenous Fluids Infused in 24 hours
Total IV fluids = Total fluid resuscitation volume + Total insulin volume
= 8442 mL + 120 mL Total IV fluids
= 8562 mL.
Correct Answer is A
Explanation
A. External cardiac pacemaker: If atropine is ineffective in treating symptomatic sinus bradycardia, the next step is the use of an external cardiac pacemaker which helps regulate the heart rate by providing electrical stimulation to the heart, addressing the bradycardia and improving circulation.
B. Amiodarone: Amiodarone is an antiarrhythmic drug used for treating ventricular arrhythmias or atrial fibrillation, not for bradycardia. The priority for bradycardia management is pacing rather than antiarrhythmic medications.
C. Magnesium: Magnesium is primarily used for treating specific arrhythmias like torsades de pointes, particularly in the presence of hypomagnesemia. It is not indicated for symptomatic sinus bradycardia, especially after atropine fails.
D. Cardioversion: Cardioversion is used to treat arrhythmias such as atrial fibrillation or supraventricular tachycardia, not bradycardia. Since the issue is a slow heart rate, not an abnormal rhythm needing electrical shock, cardioversion is not appropriate in this case.
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