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 A
Explanation
A. Lower oxygen saturations of 93% to 94%
In an older adult client with a pneumothorax, the nurse could expect to observe lower oxygen saturations of 93% to 94%. A pneumothorax involves the accumulation of air in the pleural space, which can compress the lung and impair gas exchange, leading to hypoxemia (low blood oxygen levels). Decreased oxygen saturations would be a common finding in this condition.
B. Higher oxygen saturations of 98% to 99%
Higher oxygen saturations would be less likely in a client with a pneumothorax due to impaired gas exchange resulting from lung compression. Oxygen saturations are more likely to be lower in this condition, as indicated in option A.
C. Lower energy expenditure
While a pneumothorax may cause discomfort and dyspnea, which could potentially decrease energy expenditure due to reduced activity levels, it is not a direct physiological effect of the condition. Energy expenditure would depend on various factors, including the severity of symptoms and the individual's overall health status.
D. Increased lung capacity
A pneumothorax typically results in a decrease in lung capacity rather than an increase. The accumulation of air in the pleural space causes partial or complete collapse of the affected lung, reducing its ability to expand and decreasing overall lung capacity. Therefore, increased lung capacity would not be expected in a client with a pneumothorax.
Correct Answer is A
Explanation
A. Provide humidified oxygen.
Humidified oxygen adds moisture to the air, which can help to thin secretions in the airway. Thinning the secretions makes them easier to clear, particularly for patients with copious and tenacious secretions, such as those following a tracheostomy.
B. Perform chest physiotherapy prior to suctioning.
Chest physiotherapy techniques, such as percussion and vibration, can help to mobilize secretions in the lungs and airways. While this may indirectly assist in clearing secretions, it does not directly address the issue of thinning the secretions, which is the primary concern in this scenario.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Prelubricating the suction catheter tip with sterile saline before suctioning can help reduce friction and potential trauma to the airway. While this can be beneficial for airway management, it does not directly address the need to thin copious and tenacious secretions.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.
Hyperventilating the client with 100% oxygen before suctioning is not recommended. It can lead to respiratory alkalosis, which is a condition characterized by decreased levels of carbon dioxide in the blood. This can worsen the client's condition and may lead to adverse effects. Additionally, it does not directly address the need to thin secretions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.