A nurse is providing teaching to a client about manifestations of pulmonary embolism (PE). Which of the following findings should the nurse include in the teaching? (Select All that Apply.)

Chest pain that worsens with deep breathing

Shortness of breath

Facial weakness that worsens at night

Bloody sputum

Difficulty speaking

Answer and Explanation

Correct Answer : A

A. Chest pain that worsens with deep breathing, also known as pleuritic pain, is a hallmark symptom of pulmonary embolism. It occurs due to inflammation of the pleura caused by the obstruction in the pulmonary vasculature.

B. Shortness of breath is one of the most common and early signs of a pulmonary embolism. It occurs due to reduced oxygenation resulting from blocked blood flow in the lungs.

C. Facial weakness that worsens at night is not a manifestation of pulmonary embolism. This symptom is more commonly associated with neurological conditions such as myasthenia gravis.

D. Bloody sputum, or hemoptysis, is a possible symptom of pulmonary embolism. It results from pulmonary infarction, which occurs when lung tissue is damaged due to reduced blood flow.

E. Difficulty speaking is not typically associated with pulmonary embolism. This symptom may be more indicative of neurological events such as stroke.

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Correct Answer is A

Explanation

A. Administering a bronchodilator before postural drainage helps open the airways, making it easier to mobilize and clear secretions during the procedure. This improves the effectiveness of the therapy.

B. Restricting fluid intake before the procedure is not appropriate. Adequate hydration is essential to thin secretions, making them easier to clear during postural drainage.

C. While deep breathing exercises are beneficial for lung expansion and oxygenation, they are not specifically required immediately after postural drainage. The focus is on clearing secretions during the procedure.

D. The supine position is not ideal for postural drainage. The client should be placed in specific positions depending on the lung segment being targeted, such as Trendelenburg or lateral decubitus positions, to facilitate drainage by gravity.

A. Clamp the chest tube near the water seal. B. Reposition the client toward the left side. C. Continue to monitor the client. D. Immediately notify the provider.

Correct Answer is C

Explanation

A. Clamping the chest tube near the water seal is not recommended because it can lead to complications such as a tension pneumothorax. The chest tube should remain unclamped unless instructed by the healthcare provider.

B. Repositioning the client may be necessary if the rise in the water seal chamber is due to a physical obstruction or positioning issue. However, this is not the first action to take.

C. A rise in the water seal chamber with inspiration (tidal fluctuation) is a normal finding in a chest tube system. It indicates that the lung is re-expanding and that the pleural space is still connected to the atmosphere. The nurse should continue to monitor the client and the chest tube system for any other changes.

D. Immediate notification of the provider is not necessary unless there are other signs of complications, such as sudden changes in the drainage amount, a lack of fluctuation, or signs of respiratory distress.

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A nurse is providing teaching to a client about manifestations of pulmonary embolism (PE). Which of the following findings should the nurse include in the teaching? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

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