A triage nurse is assessing a client in an emergency department.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for Correct Choices
• Pulmonary embolism: The client presents with sudden, severe chest pain rated 10/10, tachycardia (122/min), tachypnea (25/min), hypotension (77/45 mm Hg), and hypoxemia (SpO₂ 85%). These findings are consistent with a massive pulmonary embolism causing impaired pulmonary circulation and right-sided cardiac strain. Anxiety and “feels like something bad is going to happen” are also common subjective findings.
• Elevate head of the bed: This positioning improves lung expansion, decreases work of breathing, and enhances oxygenation in a client with impaired pulmonary perfusion.
• Administer anticoagulant: Anticoagulants (e.g., heparin) are first-line treatment to prevent further clot formation and reduce progression of the embolism.
• Respiratory effort: Monitoring work of breathing helps evaluate worsening hypoxia and effectiveness of oxygenation/ventilation support.
• aPTT (pTT): If heparin is used, aPTT is monitored to ensure therapeutic anticoagulation and prevent bleeding complications
Rationale for Incorrect Choices
• Tension pneumothorax: Would present with absent or markedly diminished breath sounds on one side, tracheal deviation, and unilateral chest findings—none are present (lung sounds are vesicular bilaterally and trachea is midline).
• Gastric reflux disease: Would cause burning epigastric pain, often related to meals, not severe hypoxia, hypotension, or tachycardia.
• Palpitations: Would not explain severe hypotension, hypoxemia, or respiratory distress.
• Teach client to avoid fried and spicy foods: Appropriate for GERD, not acute cardiopulmonary collapse.
• Encourage client to consume less caffeine: May reduce palpitations or anxiety symptoms but does not address life-threatening hypoxia and hypotension.
• Assist with chest tube insertion: Indicated for tension pneumothorax, not pulmonary embolism.
• Chest tube drainage: Not applicable because no chest tube is indicated for pulmonary embolism.
• Heart rate irregularity: Not the primary issue; tachycardia is present but rhythm irregularity is not described.
• Epigastric pain: Not consistent with the presenting cardiopulmonary emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","H"]
Explanation
Rationale:
A. A blood pressure of 148/94 mm Hg at 30 weeks’ gestation is elevated and concerning for gestational hypertension or preeclampsia. In combination with other findings (headache, right upper quadrant pain, edema, hyperreflexia), this requires immediate follow-up.
B. The client has 1+ dependent edema, which in pregnancy—especially when paired with hypertension and other symptoms—can indicate fluid retention associated with preeclampsia. This finding should be further evaluated for progression or worsening edema.
C. A fetal heart rate of 140/min is within the normal range (110–160/min), and no contractions are noted. At this time, there is no indication of fetal distress based on the provided information.
D. A rapid weight gain of 0.68 kg (1.5 lb) in one week during pregnancy can indicate fluid retention, which is a concerning sign of preeclampsia when combined with hypertension and edema.
E. Nausea and vomiting in the second half of pregnancy, especially with right upper quadrant pain and hypertension, can indicate liver involvement from severe preeclampsia (possible HELLP syndrome). This requires prompt follow-up.
F. A fundal height of 29 cm at 30 weeks’ gestation is appropriate (fundal height in cm approximately equals gestational age ± 2 cm), so this finding is expected.
G. Respirations are even and nonlabored with clear lung sounds and normal oxygen saturation, indicating no respiratory compromise at this time.
H. Deep tendon reflexes of 3+ indicate hyperreflexia, which is a hallmark sign of worsening preeclampsia and possible impending seizures (eclampsia). This requires urgent follow-up.
Correct Answer is B
Explanation
Rationale:
A. Petroleum-based products (such as petroleum jelly) are flammable and should not be used near oxygen therapy due to increased fire risk. Water-based lubricants are safer for dryness.
B. Cotton blankets are safe to use with oxygen therapy because cotton is a natural fiber that does not easily generate static electricity or pose a significant fire hazard. This statement reflects appropriate understanding of oxygen safety precautions.
C. Nail polish and its fumes are flammable, and using or storing such products near oxygen equipment increases the risk of fire. Oxygen supports combustion, making flammable substances especially dangerous.
D. Smoking is strictly prohibited in any environment where oxygen is in use or stored, as oxygen greatly increases the risk of rapid ignition and severe fire hazards. This is a critical safety teaching point for all clients on home oxygen therapy.
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