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 B

Explanation

A. Decrease chest wall compliance: Chest wall compliance refers to the ability of the chest to expand and contract, and fentanyl does not directly affect this function. ARDS typically causes decreased compliance, but the medication’s primary role is not to address this issue.

B. Induce sedation: Fentanyl is a potent opioid analgesic that is used for its sedative and analgesic properties in clients who are mechanically ventilated. It helps to manage pain and anxiety, making the patient more comfortable and often necessary to facilitate ventilation and reduce discomfort.

C. Decrease respiratory secretions: Fentanyl does not primarily act to decrease respiratory secretions. Medications like anticholinergics (e.g., atropine) are used to decrease secretions, not opioids like fentanyl.

D. Suppress respiratory effort: While fentanyl may help reduce respiratory effort indirectly by providing sedation and pain relief, its primary purpose in this scenario is not to suppress respiratory effort. Its purpose is to manage pain and provide sedation, not control respiratory drive.

A. Flaccidity B. Rigidity in the upper extremities C. Decerebrate posturing D. Decorticate posturing

Correct Answer is D

Explanation

A. Flaccidity: Flaccidity implies a complete lack of muscle tone and limpness. The patient in the image exhibits rigidity and specific posturing, which is the opposite of flaccidity.

B. Rigidity in the upper extremities: While there is rigidity, this option doesn't capture the specific pattern of posturing. The rigidity is part of a distinct decorticate pattern involving both upper and lower extremities in a specific way.

C. Decerebrate posturing: Decerebrate posturing is characterized by rigid extension of all four limbs, with pronation of the forearms. The image clearly shows flexion of the arms, which is the defining characteristic of decorticate posturing.

D. Decorticate posturing: The posture depicted in the image, with the arms flexed at the elbows and wrists and held close to the body, while the legs are extended, is the hallmark of decorticate posturing. This indicates severe brain injury above the level of the midbrain.

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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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Correct Answer is B

Explanation

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Correct Answer is D

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