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 B

Explanation

A. Administering supplemental oxygen is appropriate if the low oxygen saturation is confirmed, but the nurse should first verify the accuracy of the reading to avoid unnecessary interventions.

B. Checking the position of the pulse oximeter probe and ensuring it is properly attached is the first step. Faulty probe placement or technical issues can cause inaccurate readings, so confirming the validity of the drop in SpO2 is essential before taking further action.

C. Assessing the client's airway for obstruction is critical if the low SpO2 is verified and no technical issues are found. However, this step follows confirming the accuracy of the pulse oximetry reading.

D. Notifying the healthcare provider is necessary if the drop in SpO2 is confirmed and persists despite initial nursing interventions, but it is not the first action.

A. Anxiety attack B. Pneumonia C. Pulmonary embolism D. Asthma exacerbation

Correct Answer is C

Explanation

A. While anxiety can cause rapid breathing and confusion, the patient's clinical presentation (dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation) is more consistent with a serious physical condition, such as a pulmonary embolism, rather than an anxiety attack.

B. Pneumonia could cause dyspnea and confusion, but the rapid onset of symptoms, along with the patient's history of prolonged bed rest and risk factors, suggests a pulmonary embolism rather than pneumonia.

C. Pulmonary embolism (PE) is a life-threatening condition that can occur in patients on prolonged bedrest, especially after a pelvic fracture. The patient’s symptoms of dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation are classic signs of PE. This requires immediate intervention, including anticoagulation and possibly thrombolytic therapy.

D. Asthma exacerbation typically presents with wheezing and difficulty breathing, but it would not typically cause the severe hypotension, confusion, and rapid oxygen desaturation seen in this patient.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During assessment of a client on the respiratory unit, the pulse oximetry monitor indicates a drop of SpO2 from 98% to 87% over four hours in a client who previously had normal range oxygen saturation level. Which of the following actions should the nurse perform first?

Correct Answer is B

Explanation

A patient on prolonged bedrest following a pelvic fracture becomes dyspneic and confused. Pulse = 135 beats/minute, blood pressure = 90/50 mmHg, respirations = 36/minute, Oxygen saturation starts dropping rapidly. Which of the following conditions should the nurse prepare to treat for this patient?

Correct Answer is C

Explanation

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