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 ["5"]
Explanation
The patient has an order for heparin 100 units over one hour. Heparin from the pharmacy comes as 10,000 units in 500 ml. The nurse should set the pump to deliver how many ml/hr?.
Step 1: Calculate the concentration of the heparin solution. 10,000 units ÷ 500 mL = 20 units/mL.
Step 2: Determine the volume of solution required to deliver 100 units. 100 units ÷ (20 units/mL) = 5 mL.
Step 3: The infusion is to be delivered over one hour. 5 mL ÷ 1 hour = 5 mL/hr. The nurse should set the pump to deliver 5 mL/hr.
Correct Answer is ["150"]
Explanation
Step 1 is: 600 mg of Clindamycin in 50 mL is to run over 20 minutes.
Step 2 is: To find mL/hr, convert the minutes to hours by dividing 60 min by 20 min. 60 min ÷ 20 min = 3.
Step 3 is: Multiply the total volume of 50 mL by the conversion factor of 3. 50 mL × 3 = 150 mL. Final calculated answer is 150 mL/hr. *.
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