A nurse suspects that her patient has developed a pulmonary embolus (PE). Which assessment finding would lead to this nursing judgment?

Varicose veins.

Thick green sputum.

Hypertension.

Sudden dyspnea.

Answer and Explanation

The Correct Answer is D

A. While varicose veins can be a risk factor for deep vein thrombosis (DVT), which in turn can lead to a PE, they are not an acute symptom of a PE.

B. Thick green sputum is more indicative of a respiratory infection, such as pneumonia, rather than a pulmonary embolus.

C. Hypertension can be seen in various conditions but is not a primary indicator of PE.

D. Sudden dyspnea (difficulty breathing) is a classic sign of a pulmonary embolus, as the clot obstructs blood flow to the lungs, leading to respiratory distress.

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Correct Answer is C

Explanation

A. While an increased respiratory rate may occur, it does not directly lead to hyperinflation of the uninjured lung due to tension pneumothorax.

B. In a tension pneumothorax, air enters the pleural space and does not exhale effectively; it is not about exhalation.

C. Trapped air in the pleural cavity increases pressure, collapsing the lung and pushing mediastinal structures (like the heart) to the opposite side, thereby reducing venous return and cardiac output.

D. Retained CO2 is not a direct cause of tension pneumothorax; the main issue is the pressure from trapped air affecting lung function and hemodynamics.

A. Creatine kinase level B. Homocysteine level C. Serum high-density lipoproteins (HDL) D. Serum potassium

Correct Answer is B

Explanation

A. Creatine kinase is an enzyme released when muscle tissue is damaged, often used in diagnosing muscle injuries or heart attacks, not coronary artery disease risk.

B. Elevated homocysteine levels are associated with an increased risk for coronary artery disease as it can damage the blood vessel walls and promote clot formation.

C. High levels of serum high-density lipoproteins (HDL) are protective against coronary artery disease, not a risk factor.

D. Serum potassium is important for cardiovascular health, but it does not directly correlate with coronary artery disease risk.

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A nurse suspects that her patient has developed a pulmonary embolus (PE). Which assessment finding would lead to this nursing judgment?

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