After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

Administer IV opioids as needed for pain.

Teach how to use incentive spirometry.

Monitor for confusion and restlessness.

Observe for signs of increased bleeding.

Answer and Explanation

The Correct Answer is D

A. While pain management is important, it is not the most critical intervention compared to monitoring for bleeding, which can be life-threatening.

B. Teaching the client how to use incentive spirometry is important for improving lung function and preventing complications like atelectasis. However, in the context of a pulmonary embolism (PE), the immediate priority is to monitor for signs of increased bleeding due to the anticoagulant or thrombolytic therapy often used to treat PE. This is crucial to prevent potentially life-threatening complications.

C. Confusion and restlessness could indicate hypoxia, which is important to monitor in a PE patient. However, the immediate risk of bleeding due to anticoagulation therapy takes precedence.

D. Patients with a pulmonary embolism are typically treated with thrombolytic or anticoagulant therapy to prevent further clot formation and to help dissolve the existing clot. Anticoagulants significantly increase the risk of bleeding, making it crucial to monitor for signs of increased bleeding as a priority in the plan of care.

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Correct Answer is D

Explanation

A) Incorrect - Skin redness might indicate irritation, but the initial focus should be on the client's sensation.
B) Incorrect - Decreasing the strength of the electrical signals might be premature if the sensation is normal.
C) Incorrect - The amount of gel coating on the electrodes might not be the primary issue if the client is feeling a tingling sensation.
D) Correct- A tingling sensation is normal and expected when using a TENS unit, and it does not indicate any harm or damage to the skin or nerves. However, the sensation should not be painful or unpleasant for the client, and the nurse should adjust the intensity of the electrical signals accordingly.

Correct Answer is ["0.3"]

Explanation

To calculate the mL of dalteparin to administer, we need to determine the total number

of units required for the client and then convert it to the volume based on the concentration provided.

First, we need to calculate the total number of units required: Weight of the client: 110 pounds

Dalteparin dosage: 150 units/kg Duration of treatment: 4 months

To convert the client's weight from pounds to kilograms, we divide it by 2.2: 110 pounds / 2.2 = 50 kilograms

Next, we calculate the total number of units required:

150 units/kg * 50 kilograms = 7,500 units

Now we can calculate the volume to administer:

7,500 units / 7,500 units/0.3 mL = 0.3 mL

Therefore, the nurse should administer 0.3 mL of dalteparin.

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After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Correct Answer is D

Explanation

A client who weighs 110 pounds receives a prescription for dalteparin 150 units/kg subcutaneously daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

Correct Answer is ["0.3"]

Explanation

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

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Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

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