The nurse assigned a patient who was diagnosed with a pulmonary embolism. Which of the following potential complication during the treatment for pulmonary embolism should the nurse monitor for?

Hyperglycemia

Hemorrhage

Septic shock

Urinary retention

Answer and Explanation

The Correct Answer is B

A. Hyperglycemia: Hyperglycemia is not a typical complication of pulmonary embolism (PE) treatment. While stress or steroid use may elevate blood glucose, it is not directly related to anticoagulation or thrombolytic therapy, which are standard PE treatments.

B. Hemorrhage: Hemorrhage is a major potential complication of PE treatment because anticoagulants (e.g., heparin, warfarin) and thrombolytic agents increase the risk of bleeding. The nurse must monitor for signs such as hematuria, gastrointestinal bleeding, bruising, or hypotension, as prompt detection is critical for patient safety.

C. Septic shock: Septic shock is not a common complication of PE treatment unless there is an unrelated infection. PE and its pharmacologic management do not inherently predispose the patient to sepsis or septic shock.

D. Urinary retention: Urinary retention is not a direct complication of PE or its standard therapy. While immobility or opioid use may contribute to retention, it is not a primary concern related to PE management.

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Correct Answer is C

Explanation

A. Call the provider: Notifying the provider may eventually be necessary, but immediate assessment is required first to determine the cause of constant bubbling. Calling the provider without assessing the system does not address the potential underlying problem.

B. Apply a sterile dressing to the chest tube insertion site: Applying a dressing is important for preventing infection but will not stop or explain constant bubbling in the water seal chamber. The priority is identifying whether the bubbling is due to an air leak.

C. Assess the chest tube connections: Constant bubbling in the water seal chamber usually indicates an air leak. The nurse should first inspect all tubing connections, insertion site, and the drainage system to locate and correct any leaks before notifying the provider or taking further action. Proper assessment ensures patient safety and prevents loss of negative pressure.

D. Place the patient on oxygen: Oxygen supplementation may be indicated for hypoxemia but does not address the cause of constant bubbling in the chest tube system. The immediate priority is identifying and correcting any mechanical or tubing-related issues.

A. Administer sedatives B. Secure the tube C. Auscultate lung sounds D. Draw an arterial blood gas (ABG)

Correct Answer is C

Explanation

A. Administer sedatives: Sedation is important after intubation to ensure patient comfort and prevent agitation, but it is not the immediate priority. Confirming proper tube placement and ensuring effective ventilation must occur first to prevent hypoxia or accidental esophageal intubation.

B. Secure the tube: Securing the ETT prevents accidental displacement, which is essential for ongoing airway management. However, before securing, the nurse must first verify that the tube is correctly positioned in the trachea to ensure effective ventilation.

C. Auscultate lung sounds: The first action after ETT placement is to confirm correct placement by assessing bilateral breath sounds and observing for chest rise. This ensures that the tube is in the trachea and not the esophagus, preventing life-threatening hypoxia and guiding further interventions.

D. Draw an arterial blood gas (ABG): ABG analysis provides valuable information about oxygenation and ventilation status, but it is performed after confirming proper tube placement and establishing effective ventilation. Immediate verification of the airway takes priority over laboratory assessment.

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The nurse assigned a patient who was diagnosed with a pulmonary embolism. Which of the following potential complication during the treatment for pulmonary embolism should the nurse monitor for?

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Naxlex Comprehensive Predictor Exams

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Explanation

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