A nurse is reinforcing teaching for a client who presents with a pulmonary embolism. Which of the following information should the nurse provide?
Treatment is not needed if the client is asymptomatic.
Treatment is not needed if the pulmonary embolism is intermediate.
Treatment is not needed if the client is hemodynamically stable.
Treatment is needed for all clients who have a pulmonary embolism.
The Correct Answer is D
A. Treatment is not needed if the client is asymptomatic.
Even asymptomatic pulmonary embolisms can lead to complications such as progression to symptomatic PE or development of chronic thromboembolic pulmonary hypertension. Therefore, treatment is necessary to prevent these complications.
B. Treatment is not needed if the pulmonary embolism is intermediate.
The severity of a pulmonary embolism is determined by various factors, including the size and location of the clot and the degree of obstruction in the pulmonary arteries. Intermediate-risk pulmonary embolisms still require treatment to prevent complications and reduce the risk of progression to a more severe or life-threatening condition.
C. Treatment is not needed if the client is hemodynamically stable.
Hemodynamic stability refers to the client's circulatory status and whether they are maintaining adequate blood flow to vital organs. While hemodynamically stable clients may not require aggressive interventions such as thrombolytic therapy or surgical embolectomy, they still require anticoagulant therapy to prevent further clot formation and reduce the risk of complications.
D. Treatment is needed for all clients who have a pulmonary embolism.
Pulmonary embolism (PE) is a serious and potentially life-threatening condition that requires prompt treatment. Regardless of the severity of symptoms or the client's hemodynamic stability, treatment is necessary to prevent complications and reduce the risk of recurrence. Treatment typically includes anticoagulant therapy to prevent further clot formation and may include additional interventions such as thrombolytic therapy or surgical interventions in certain cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Muscle twitching
Muscle twitching is not a typical manifestation of oxygen toxicity. Instead, muscle twitching may be indicative of other conditions such as electrolyte imbalances (e.g., hypocalcemia or hypomagnesemia), neuromuscular disorders, or overstimulation of the nervous system.
B. Metallic taste in mouth
A metallic taste in the mouth is not commonly associated with oxygen toxicity. Instead, a metallic taste in the mouth may occur as a side effect of certain medications, dental issues, or as a symptom of other medical conditions such as acid reflux or oral infections.
C. Facial flushing
Facial flushing is a characteristic finding in oxygen toxicity. When exposed to high levels of oxygen over an extended period, individuals may experience facial flushing due to the vasodilatory effects of oxygen on blood vessels. This dilation of blood vessels leads to increased blood flow to the face, resulting in flushing or reddening of the skin.
D. Periorbital edema
Periorbital edema, or swelling around the eyes, is not a typical manifestation of oxygen toxicity. Instead, periorbital edema may occur as a result of various other conditions such as allergies, sinusitis, or fluid retention. It is not directly related to exposure to high levels of oxygen.
Correct Answer is C
Explanation
A. Inspiratory stridor
Inspiratory stridor is a high-pitched, musical sound heard during inspiration and is typically caused by turbulent airflow due to partial obstruction of the upper airway. It is commonly associated with conditions such as croup, epiglottitis, or anaphylaxis. While respiratory distress may occur in a pneumothorax, inspiratory stridor specifically suggests an upper airway obstruction rather than a pneumothorax.
B. Expiratory wheeze
Expiratory wheeze is a high-pitched, musical sound heard during expiration and is typically associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchiolitis. Wheezing occurs due to narrowing of the airways, leading to turbulent airflow during expiration. While a pneumothorax can cause respiratory distress, it is not typically associated with wheezing.
C. Absence of breath sounds
The absence of breath sounds over a particular area of the chest can indicate a pneumothorax. In a pneumothorax, air accumulates in the pleural space, causing partial or complete collapse of the lung and preventing it from making contact with the chest wall. This absence of breath sounds over the affected area is a classic finding in a pneumothorax and is crucial for its detection.
D. Coarse crackles
Coarse crackles are discontinuous, bubbling or popping sounds heard during inspiration and may be indicative of conditions such as pneumonia, pulmonary edema, or bronchiectasis. These crackles are typically heard when there is fluid or mucus in the airways. While a pneumothorax can cause respiratory distress, it does not typically produce crackles on auscultation.
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