A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?
Begin oxygen therapy.
Start an IV infusion of lactated Ringer’s.
Initiate cardiac monitoring.
Administer IV morphine.
The Correct Answer is A
a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.
b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.
c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.
d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.
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Related Questions
Correct Answer is C
Explanation
a. Hyperactive bowel sounds: Shock is more likely to be associated with decreased bowel sounds rather than hyperactive bowel sounds.
b. Increased urine output: In the early stages of shock, there may be an increase in urine output as the body attempts to compensate. However, as shock progresses, renal perfusion decreases,
leading to decreased urine output.
c. Hypotension: Hypotension is a key indicator of shock. In shock, there is insufficient blood flow to meet the body's oxygen and nutrient needs, resulting in a drop in blood pressure.
d. Bradycardia: Shock typically leads to an increased heart rate (tachycardia) as the body tries to compensate for decreased cardiac output. Bradycardia is not a typical finding in the early stages of shock.
Correct Answer is B
Explanation
a. Decreased calcium level: NG tube drainage is more likely to result in hypokalemia (decreased potassium) than hypocalcemia (decreased calcium).
b. Decreased potassium level: NG tube drainage, which contains stomach contents, can lead to loss of potassium. Monitoring for hypokalemia is crucial as it can result in cardiac dysrhythmias.
c. Elevated magnesium level: NG tube drainage is not typically associated with an increase in magnesium levels.
d. Elevated sodium level: NG tube drainage may contribute to sodium loss, leading to hyponatremia, rather than hypernatremia.
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