A nurse is reviewing orders for a patient who has acute dyspnea and diaphoresis.
The patient states she is anxious and is unable to get enough air.
Her vital signs are heart rate 117 bpm, respirations 38 breaths/min, temperature 38.4 °C, and BP 110/54 mmHg.
Which of the following nursing actions is the priority?
Administer heparin via IV infusion.
Administer oxygen therapy.
Obtain a spiral CT scan.
Notify the provider.
The Correct Answer is B
Choice A rationale
Administering heparin via IV infusion is an important long-term treatment for a pulmonary embolism but is not the immediate priority. Heparin is an anticoagulant that prevents the formation of new clots and the enlargement of existing ones. However, the most life-threatening issue for this patient is hypoxemia due to impaired gas exchange. The immediate priority must be to address the patient's acute respiratory distress and stabilize their oxygen saturation.
Choice B rationale
Administering oxygen therapy is the priority nursing action for a patient with suspected pulmonary embolism. The patient's symptoms of acute dyspnea and rapid respirations (38 breaths/min, normal range is 12-20 breaths/min) indicate significant respiratory compromise and hypoxemia. Supplying supplemental oxygen directly addresses the ventilation-perfusion mismatch and improves tissue oxygenation, which is the most critical and life-threatening issue.
Choice C rationale
Obtaining a spiral CT scan is a diagnostic test to confirm a pulmonary embolism. While this is a critical step in the diagnostic pathway, it is not the immediate priority nursing action. The patient is showing signs of acute respiratory distress and physiological instability. The nurse must first stabilize the patient's oxygenation and vital signs before any further diagnostic procedures can be safely performed. Patient stabilization precedes definitive diagnosis.
Choice D rationale
Notifying the provider is an essential step in the management of a pulmonary embolism, but it is not the absolute priority. The patient's vital signs and acute symptoms (heart rate 117 bpm, respirations 38 breaths/min) indicate an unstable state that requires immediate intervention. The nurse should initiate life-saving actions, such as oxygen therapy, to stabilize the patient's condition before or while notifying the provider of the emergent situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Dyspnea on exertion is the most common initial symptom of pulmonary hypertension. This condition involves increased vascular resistance in the pulmonary arteries, which elevates pressure and makes it more difficult for the right ventricle to pump blood to the lungs. This reduced cardiac output and impaired gas exchange lead to shortness of breath during physical activity.
Choice B rationale
Fever is not a typical manifestation of pulmonary hypertension. Fever is a systemic response to an infectious or inflammatory process. Pulmonary hypertension is a hemodynamic disorder characterized by elevated blood pressure in the lung arteries. While an underlying inflammatory condition could cause fever, fever itself is not a direct symptom of pulmonary hypertension.
Choice C rationale
Increased appetite is not a typical manifestation of pulmonary hypertension. In fact, patients with this condition may experience anorexia, nausea, and vomiting, especially in advanced stages, due to gastrointestinal congestion from right-sided heart failure. Increased appetite is not a recognized symptom and would be an unexpected finding.
Choice D rationale
Intermittent claudication is a symptom of peripheral artery disease, caused by arterial insufficiency in the legs. It presents as leg pain during exercise that is relieved by rest. This is not a manifestation of pulmonary hypertension, which affects the pulmonary circulation and heart, not the systemic arteries supplying the limbs
Correct Answer is C
Explanation
Choice A rationale
Respiratory alkalosis is characterized by a high pH (above 7.45) and a low PaCO$_2$ (below 35). This is typically caused by hyperventilation, where the patient is blowing off too much carbon dioxide. The patient's ABGs (pH 7.30, PaCO$_2$ 50) show a low pH and a high PaCO$_2$, which is the opposite of respiratory alkalosis.
Choice B rationale
Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO$_3$ (below 22). While the patient's pH is low (7.30), the HCO$_3$ (26) is within the normal range. The primary imbalance is the elevated PaCO$_2$ (50), indicating a respiratory problem rather than a metabolic one like diabetic ketoacidosis.
Choice C rationale
The patient's ABGs show a low pH (7.30, normal 7.35-7.45), indicating acidosis. The high PaCO$_2$ (50, normal 35-45) indicates a respiratory cause for the acidosis, as carbon dioxide acts as an acid in the blood. The normal HCO$_3$ (26, normal 22-26) suggests that the metabolic system has not yet compensated. This pattern is characteristic of respiratory acidosis caused by hypoventilation.
Choice D rationale
Metabolic alkalosis is characterized by a high pH (above 7.45) and a high HCO$_3$ (above 26). Cushing syndrome can sometimes cause metabolic alkalosis. However, the patient's ABGs (pH 7.30, HCO$_3$ 26) show a low pH and a normal HCO$_3$, which is inconsistent with metabolic alkalosis. .
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