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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Increased heart rate: In hypovolemic shock, the body compensates for decreased blood volume by increasing the heart rate to maintain cardiac output and perfusion to vital organs. This is one of the first signs of shock, especially in response to blood loss or fluid depletion.

B. Increased deep tendon reflexes: Increased deep tendon reflexes are not a typical sign of hypovolemic shock. They are more commonly associated with neurological conditions or electrolyte imbalances, not circulatory shock.

C. Pulse oximetry 96%: A pulse oximetry reading of 96% is within the normal range and does not suggest hypovolemic shock. In shock, oxygen saturation would typically decrease, especially if perfusion is compromised, leading to hypoxia and lower oxygen levels.

D. Widening pulse pressure: A widening pulse pressure is generally associated with conditions such as increased intracranial pressure or head injury. In hypovolemic shock, pulse pressure tends to narrow due to a decrease in stroke volume and compensatory mechanisms.

A. Initiate client decontamination B. Place the clients in isolation. C. Administer antibiotic therapy D. Treat clients with an antitoxin

Correct Answer is C

Explanation

A. Initiate client decontamination: While decontamination might seem intuitive, anthrax (Bacillus anthracis) is primarily acquired through inhalation of spores, ingestion, or skin contact with spores. It is not contagious from person to person. Therefore, routine external decontamination of is not necessary.

B. Place the clients in isolation: Isolation may be necessary for individuals who are showing symptoms of anthrax, but for those who may have been exposed without symptoms, antibiotic therapy is more urgent. Isolation would follow if clinical signs of infection develop.

C. Administer antibiotic therapy: After potential exposure to anthrax, the appropriate action is to administer prophylactic antibiotics, such as ciprofloxacin or doxycycline. Antibiotics are the first line of defense to prevent the infection, particularly exposure.

D. Treat clients with an antitoxin: Antitoxins are used in cases where infection is confirmed and symptoms are present, particularly in severe forms of anthrax. However, administering antibiotics for prophylaxis is the initial and most important action.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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