A patient is hospitalized with a second episode of pulmonary embolism (PE) despite anticoagulation therapy. What is the nurse's best action?

Teach the patient to use a soft bristled toothbrush

Instruct the patient to eliminate vitamin K from the diet

Perform a medication reconciliation

Refer the patient to a chronic illness support group

Answer and Explanation

The Correct Answer is C

A. Teach the patient to use a soft bristled toothbrush: This teaching is appropriate for patients receiving anticoagulation therapy to reduce bleeding risk. However, it does not address the urgent clinical concern of recurrent pulmonary embolism while already on anticoagulants, which suggests possible treatment failure, nonadherence, drug interactions, or incorrect dosing.

B. Instruct the patient to eliminate vitamin K from the diet: For patients taking warfarin, vitamin K intake should remain consistent rather than eliminated. Complete avoidance can destabilize anticoagulation control and increase INR variability. Additionally, this intervention does not directly address why a second PE occurred despite therapy.

C. Perform a medication reconciliation: A recurrent PE while on anticoagulation raises concern for nonadherence, incorrect dosing, drug–drug interactions, or subtherapeutic anticoagulation levels. Medication reconciliation helps identify discrepancies, missed doses, or interactions that may have reduced anticoagulant effectiveness and is a priority safety action.

D. Refer the patient to a chronic illness support group: Psychosocial support may be beneficial long term, but it does not address the immediate clinical issue of recurrent thromboembolism. The priority is to determine why anticoagulation therapy failed and prevent further potentially life-threatening embolic events.

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Infection: Central venous catheters used for CVP monitoring provide direct access to the bloodstream, increasing the risk of catheter-related bloodstream infections. The nurse must monitor for signs of infection such as fever, redness, swelling, or purulent drainage at the insertion site and follow strict aseptic technique during care.

B. Hypervolemia: CVP monitoring measures central venous pressure to assess fluid status, but the presence of the catheter itself does not cause hypervolemia. Hypervolemia is a patient condition rather than a complication of the monitoring system, so it is not directly monitored as a catheter-related complication.

C. Air embolism: An air embolism can occur if air enters the central venous catheter during insertion, dressing changes, or disconnection. The nurse monitors for sudden respiratory distress, hypotension, and hypoxia, and ensures all connections are secure and the patient is positioned appropriately during procedures.

D. Pneumothorax: Pneumothorax is a potential complication during the insertion of a central venous catheter, especially with subclavian or jugular access. The nurse monitors for sudden chest pain, decreased breath sounds on the affected side, and respiratory distress, and prepares to intervene if a pneumothorax develops.

A. Tracheal deviation towards the unaffected side B. Wheezing breath sounds over the affected area C. Rales breath sounds over the affected area D. Tracheal deviation towards the affected side

Correct Answer is A

Explanation

A. Tracheal deviation towards the unaffected side: In tension pneumothorax, air accumulates in the pleural space under pressure, compressing the lung and shifting mediastinal structures. The trachea deviates away from the affected side (toward the unaffected side), which is a hallmark sign, along with hypotension, distended neck veins, and severe respiratory distress.

B. Wheezing breath sounds over the affected area: Wheezing indicates airway narrowing, commonly seen in asthma or bronchospasm. It does not reflect the pathophysiology of tension pneumothorax, which involves lung collapse and mediastinal shift rather than bronchial constriction.

C. Rales breath sounds over the affected area: Rales are fine crackles produced by fluid in the alveoli, typically seen in pulmonary edema or pneumonia. They are not characteristic of a tension pneumothorax, where breath sounds are diminished or absent over the affected side.

D. Tracheal deviation towards the affected side: Tracheal deviation toward the affected side occurs in lung collapse from atelectasis, not tension pneumothorax. In tension pneumothorax, the pressure pushes the mediastinum away from the affected side.

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A patient is hospitalized with a second episode of pulmonary embolism (PE) despite anticoagulation therapy. What is the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is A

Explanation

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