A nurse is caring for a client who has a pulmonary embolism.
The client reports sudden onset of dyspnea and chest pain.
What is the priority action by the nurse?
Administer oxygen therapy.
Obtain a chest x-ray.
Start an IV line.
Give morphine for pain.
The Correct Answer is A
The correct answer is choice A. Administer oxygen therapy. The priority action by the nurse for a client who has a pulmonary embolism is to increase perfusion and oxygenation by providing oxygen therapy.
This can help reduce hypoxemia, dyspnea, and chest pain.
Oxygen therapy can also prevent further clotting and pulmonary vasoconstriction.
Choice B is wrong because obtaining a chest x-ray is not the immediate action for a client with a pulmonary embolism. A chest x-ray can help confirm the diagnosis, but it is not a priority over oxygen therapy.
Choice C is wrong because starting an IV line is not the first action for a client with a pulmonary embolism. An IV line can facilitate the administration of fluids and medications, such as anticoagulants and thrombolytics, but it is not as urgent as oxygen therapy.
Choice D is wrong because giving morphine for pain is not the most important action for a client with a pulmonary embolism. Morphine can help relieve pain and anxiety, but it can also depress respiration and lower blood pressure, which can worsen the condition of the client.
Normal ranges for oxygen saturation are 95% to 100%.
Normal ranges for blood pressure are 120/80 mmHg or lower.
Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for respiratory rate are 12 to 20 breaths per minute.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Elevated D-dimer level.
D-dimer is a fibrin degradation product that is released when a blood clot is dissolved.A high level of D-dimer indicates an increased likelihood of blood clots, such as pulmonary embolism.A normal D-dimer level (below 500 ng/mL) can rule out pulmonary embolism in patients with low or moderate clinical pretest probability.
Choice B is wrong because decreased platelet count is not associated with pulmonary embolism.Platelet count may decrease after pulmonary embolism due to platelet activation and consumption, but it is not a risk factor for clot formation.
Choice C is wrong because low hematocrit level is not associated with pulmonary embolism.
Hematocrit level may decrease due to blood loss, hemolysis, or dilution, but it does not affect the risk of clot formation.
Choice D is wrong because high prothrombin time is not associated with pulmonary embolism.
Prothrombin time measures the time it takes for blood to clot in the presence of vitamin K-dependent factors.
A high prothrombin time indicates a deficiency or inhibition of these factors, which may increase the risk of bleeding, not clotting.
Normal ranges for D-dimer, platelet count, hematocrit, and prothrombin time may vary depending on the laboratory and the method used, but generally they are:
• D-dimer: <500 ng/mL
• Platelet count: 150-450 x 10^9/L
• Hematocrit: 36-48% for females, 40-54% for males
• Prothrombin time: 11-13 seconds
Correct Answer is A
Explanation
The correct answer is choice A.“I should avoid smoking cigarettes.” Smoking cigarettes increases the risk of blood clots and deep vein thrombosis (DVT), which can lead to pulmonary embolism (PE) if the clot travels to the lungs.Smoking also damages the blood vessels and reduces oxygen levels in the blood.
Choice B is wrong because aspirin is not a recommended medication for preventing PE.Aspirin is a type of antiplatelet drug that prevents platelets from sticking together and forming clots, but it does not affect the clotting factors in the blood that are involved in DVT and PE.Anticoagulants, also known as blood thinners, are the preferred medications for preventing and treating DVT and PE, as they prevent further clot formation and decrease the chances of new clots.
Choice C is wrong because limiting fluid intake can increase the risk of dehydration, which can thicken the blood and make it more prone to clotting.Drinking plenty of water is important for preventing DVT and PE, especially when traveling or being immobile for long periods of time.
Choice D is wrong because wearing tight-fitting socks can restrict blood flow in the legs and increase the risk of DVT and PE.
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