The nurse is assessing a client with a history of deep vein thrombosis (DVT) who is admitted for possible pulmonary embolism (PE). It is important to report which finding to the healthcare provider immediately?
Unilateral calf pain.
Intravenous site inflammation.
Pedal edema.
Difficulty breathing.
The Correct Answer is D
A. Unilateral calf pain: This is a classic sign of DVT, indicating localized clot formation in the leg. While significant, it is not as immediately life-threatening as signs of pulmonary embolism and does not require urgent reporting if PE is already suspected.
B. Intravenous site inflammation: IV site inflammation may suggest phlebitis or local irritation but is not related to the acute life-threatening nature of pulmonary embolism. It should be addressed but does not warrant immediate escalation over respiratory symptoms.
C. Pedal edema: Pedal edema is a common finding in DVT or chronic venous insufficiency and may be present without acute complications. Although it supports the history of venous thromboembolism, it is not urgent unless associated with other signs of decompensation.
D. Difficulty breathing: Sudden onset dyspnea is a hallmark symptom of pulmonary embolism and may signal impaired gas exchange or hemodynamic compromise. This finding must be reported immediately as it indicates potential life-threatening embolic obstruction in the pulmonary circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- Congestive cardiomyopathy is the most likely condition given the client’s symptoms of labored breathing, bilateral leg edema, S3 gallop, and apical pulse displacement—all signs of fluid overload and decreased cardiac output associated with heart failure.
- Applying oxygen helps manage dyspnea and improves tissue oxygenation in clients with heart failure, especially when respiratory rate is elevated and breathing is labored.
- Requesting a chest x-ray allows for visualization of pulmonary congestion or cardiomegaly, both of which are common in heart failure and can guide further treatment decisions.
- Monitoring breath sounds helps detect improvement or worsening of pulmonary congestion, such as crackles or rales, which indicate fluid buildup in the lungs.
- Monitoring urine output evaluates kidney perfusion and fluid status, which reflects the effectiveness of heart failure treatment and overall cardiac output.
- Hypertrophic cardiomyopathy typically presents with exertional syncope or chest pain, not fluid overload signs like leg edema and S3 gallop. Apical displacement also favors dilation rather than hypertrophy.
- Dilated cardiomyopathy overlaps with congestive cardiomyopathy, but the broader term “congestive” aligns more clearly with fluid overload and heart failure signs.
- Restrictive cardiomyopathy involves impaired ventricular filling but does not usually present with displaced apical pulse or bilateral edema in early stages. It is also less common in this clinical setting.
- Starting IV fluids would worsen the client’s condition by increasing preload and exacerbating fluid overload in heart failure.
- Giving the client 80 mg of aspirin is more appropriate in acute coronary syndrome, not in managing cardiomyopathy or fluid retention.
- Preparing for cardioversion is indicated in arrhythmias like atrial fibrillation with hemodynamic instability, not in a hemodynamically stable patient with heart failure.
- Monitoring platelet count is not relevant to evaluating heart failure progression or response to treatment.
- Monitoring temperature is important for infection but does not reflect cardiac or fluid status in this context.
- Monitoring cerebral perfusion pressure is reserved for neurocritical care settings and is not appropriate for routine heart failure monitoring.
Correct Answer is ["20"]
Explanation
Calculation:
Desired dose = 0.2 grams.
- Convert the desired dose from grams (g) to milligrams (mg) to match the available concentration's unit.
1 gram = 1000 mg,
Desired dose in mg = 0.2 g × 1000 mg/g
= 200 mg.
- Identify the available concentration.
Available is 50 mg per 5 mL.
= 50 mg / 5 mL
= 10 mg/mL.
- Calculate the volume to administer.
Volume (mL) = Desired dose (mg) / Concentration (mg/mL)
= 200 mg / 10 mg/mL
= 20 mL.
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