The nurse is caring for a client diagnosed with deep vein thrombosis who suddenly becomes short of breath, anxious, and restless.
The vital signs are: heart rate 130 beats/minute, respirations 42/minute, blood pressure 90/50, and pulse oximetry is 90%. An intravenous infusion of normal saline is running at 75ml/hr. The nurse elevates the head of the bed and applies nasal oxygen at 2L/min.
What action should the nurse take next?
Administer the PRN antianxiety medication.
Call the rapid response team.
Increase the intravenous infusion rate.
Prepare for mechanical ventilation.
The Correct Answer is B
Choice A rationale
Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.
Choice B rationale
Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.
Choice C rationale
Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.
Choice D rationale
Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A decrease in inflammation at the site of infection is a key indicator that antibiotic therapy is effective. Inflammation is a response to infection, so if the inflammation is reducing, it suggests that the infection is being successfully treated.
Choice B rationale
An increase in circulating neutrophils could indicate an ongoing response to infection, rather than resolution. Neutrophils are a type of white blood cell that the body produces more of when there’s an infection. Therefore, an increase in neutrophils does not necessarily indicate that the antibiotic therapy has been effective.
Choice C rationale
A positive culture and sensitivity report indicates the presence of bacteria and identifies which antibiotics the bacteria are sensitive to. While this information is crucial for selecting the most effective antibiotic, it does not indicate whether the chosen antibiotic therapy has been effective.
Choice D rationale
A symptomatic fever could indicate an ongoing infection, rather than resolution. While fever can decrease as an infection is brought under control, the presence of a symptomatic fever does not necessarily indicate that the antibiotic therapy has been effective.
Correct Answer is B
Explanation
Choice A rationale
Fewer doses of insulin may not necessarily be required with frequent self-monitoring of blood glucose. The need for insulin is determined by blood glucose levels, not the frequency of monitoring.
Choice B rationale
Frequent self-monitoring of blood glucose assists in gaining control over glucose levels. It can immediately tell you the effects of food choices, physical activity, and medication on blood glucose control.
Choice C rationale
While good blood glucose control can help minimize other health problems, frequent self- monitoring of blood glucose does not directly minimize other health problems.
Choice D rationale
Frequent self-monitoring of blood glucose is not necessarily the most cost-efficient method for glucose control. The cost efficiency depends on various factors, including the cost of testing supplies and the frequency of testing.
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