A nurse is caring for a client who develops a pulmonary embolism.
Which of the following interventions is the priority for the nurse to take?

Administer IV morphine.

Start an IV infusion of lactated Ringer's.

Begin oxygen therapy.

Initiate cardiac monitoring.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Administer IV morphine. Administering IV morphine may be necessary for pain management in a client with a pulmonary embolism. However, pain relief should not take precedence over ensuring the patient's oxygenation and cardiovascular stability. Oxygen therapy is the top priority to address hypoxia and prevent further deterioration. Once oxygenation is secured, pain management can be considered.

Choice B rationale:

Start an IV infusion of lactated Ringer's. Initiating an IV infusion of lactated Ringer's solution may be important for maintaining hydration and electrolyte balance in a patient with a pulmonary embolism. However, this is not the top priority when a client is at risk of or experiencing a pulmonary embolism. Ensuring oxygenation and cardiovascular stability takes precedence. Once the patient is stable, intravenous fluids can be administered if needed.

Choice D rationale:

Initiate cardiac monitoring. Initiating cardiac monitoring is important in assessing the patient's cardiac rhythm and identifying any dysrhythmias or changes that may occur due to the pulmonary embolism. While this is a vital step, it is not the highest priority when the client is in a state of hypoxia and respiratory distress. Oxygen therapy should be the first intervention to address the immediate threat to the patient's life.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Hypovolemic shock is characterized by a decrease in blood volume, leading to low blood pressure and compensatory mechanisms such as a high pulse rate. When the body experiences a significant loss of blood or fluid, it attempts to maintain perfusion to vital organs by increasing the heart rate to ensure an adequate blood supply. Low blood pressure and a high pulse rate are classic signs of hypovolemic shock.

Choice B rationale:

A low BP and low pulse rate are not indicative of hypovolemic shock. Hypovolemic shock is associated with a rapid and weak pulse rate as the body tries to compensate for decreased blood volume. A low pulse rate could suggest other conditions, such as bradycardia, rather than hypovolemic shock.

Choice C rationale:

High BP and high pulse rate are not typical findings in hypovolemic shock. Hypovolemic shock is characterized by low blood pressure and a high pulse rate as the body attempts to compensate for the reduced blood volume. High blood pressure is more commonly associated with conditions like hypertension, not hypovolemic shock.

Choice D rationale:

High BP and low pulse rate are not consistent with the characteristics of hypovolemic shock. As mentioned earlier, hypovolemic shock is marked by low blood pressure and a high pulse rate due to the body's efforts to maintain adequate perfusion. High blood pressure and a low pulse rate may suggest other medical conditions unrelated to hypovolemic shock.

A. Eat foods that contain plenty of potassium. B. Take the medication at bedtime. C. Take aspirin for headaches. D. Expect some swelling in the hands and feet.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the client to consume foods rich in potassium because furosemide, a loop diuretic, can lead to potassium depletion. By consuming potassium-rich foods, the client can help maintain proper electrolyte balance. Common potassium-rich foods include bananas, oranges, potatoes, and leafy greens. It is crucial to prevent hypokalemia, as it can result in adverse effects such as cardiac dysrhythmias and muscle weakness.

Choice B rationale:

Taking furosemide at bedtime is not necessary, and it is not a standard instruction. Furosemide is usually taken in the morning to avoid nocturia, as it increases urine output. This option does not address the primary concern of managing pulmonary edema and the potential electrolyte imbalances associated with furosemide use.

Choice C rationale:

Taking aspirin for headaches is not relevant to the client's condition of pulmonary edema or the use of furosemide. This choice does not provide valuable guidance to the client and may lead to unnecessary medication use.

Choice D rationale:

Expecting swelling in the hands and feet is not an appropriate instruction for a client with pulmonary edema. The goal of furosemide therapy is to reduce edema and fluid retention, not to expect or tolerate swelling. This option does not contribute to the client's well-being and recovery.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock.Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with a client who has pulmonary edema and is about to start taking furosemide.Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching?

A nurse is conducting a preoperative interview with a client who is scheduled for surgery.The client states that he takes acetylsalicylic acid 81 mg. by mouth daily.Prior to the client's upcoming surgery, the nurse should instruct the client to do which of the following?

A nurse is admitting a client who is having an exacerbation of asthma.When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following prescribed medications?

A nurse is reinforcing teaching about a heart-healthy diet with a group of clients who have hypertension. Which of the following statements by the clients indicates a need for further teaching?

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?

A nurse is collecting data from a client who has shallow respirations and a respiratory rate of 9/min.Which of the following acid-base imbalances should the nurse expect?

During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 minutes later and notes that the IV bag is empty.Which of the following actions should the nurse take?

A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility.Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who develops a pulmonary embolism.
Which of the following interventions is the priority for the nurse to take?