The nurse is educating a client about the treatment options for a pulmonary embolism. Which of the following statements would require further teaching?

“I will be discharged on Warfarin so that a clot will not develop in the future."

"A Heparin infusion is going to keep the blood clot from getting bigger."

"The purpose of the Inferior Vena Cava (IVC) Filter is to prevent the development of DVTs."

"An embolectomy is a procedure to physically remove a blood clot."

Answer and Explanation

The Correct Answer is C

A. Warfarin is commonly prescribed for long-term anticoagulation to prevent future clot formation. This statement is correct and does not require further teaching.
B. A Heparin infusion does not dissolve existing clots but prevents them from enlarging and new clots from forming, making this statement accurate.
C. The purpose of the Inferior Vena Cava (IVC) filter is to trap emboli from deep vein thrombosis (DVT) before they reach the lungs, not to prevent DVT formation. This statement is incorrect and requires further teaching.
D. An embolectomy is a surgical procedure to remove a pulmonary embolism, making this statement correct.

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Correct Answer is ["A","B","C","E","F"]

Explanation

A. Vital signs . The client has tachycardia (HR 138/min) and tachypnea (RR 28/min), which may indicate worsening heart failure or fluid overload. The low blood pressure (96/75 mmHg) is also concerning, especially with rapid ventricular response (RVR).
B. Respiratory assessment . The presence of a frequent cough with pink-tinged sputum suggests pulmonary congestion or pulmonary edema, a sign of worsening left-sided heart failure.
C. Renal function . The BUN of 28 mg/dL (elevated) and creatinine of 1.5 mg/dL (borderline high) suggest possible kidney impairment due to decreased cardiac output and poor perfusion.
D. Cardiac enzymes . The client denies chest pain or discomfort, so cardiac enzymes are not the immediate priority.
E. BNP (B-type natriuretic peptide) . BNP is a key marker of heart failure severity and helps guide treatment decisions.
F. ECG results . The atrial fibrillation with RVR increases the risk of hemodynamic instability and potential thromboembolic events, requiring urgent intervention.
G. Neurologic status . The client is alert, oriented, and following commands, so no immediate neurologic concerns are present.

A. "Try taking a mild analgesic to relieve the headache." B. "Take only one dose of nitroglycerin to reduce the risk of getting a headache." C. "We will ask the provider to prescribe a different medication for you." D. "There's nothing that can be done to relieve the headaches that nitroglycerin causes."

Correct Answer is A

Explanation

A. "Try taking a mild analgesic to relieve the headache." is correct. Nitroglycerin-induced headaches are a common side effect due to vasodilation. Mild analgesics such as acetaminophen can help alleviate the discomfort.
B. Taking only one dose to reduce the risk of a headache is inappropriate. The client should follow the prescribed dosing regimen to manage angina effectively. Skipping doses may increase the risk of angina attacks.
C. Requesting a different medication is not necessary. Nitroglycerin is an effective treatment for stable angina, and headaches typically diminish over time as the body adjusts to the medication.
D. Stating that nothing can be done to relieve the headaches is incorrect. Headaches from nitroglycerin can be managed with mild analgesics or by adjusting the timing of medication administration.

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The nurse is educating a client about the treatment options for a pulmonary embolism. Which of the following statements would require further teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has a history of heart failure. Exhibits Check the 5 findings that require immediate follow-up.

Correct Answer is ["A","B","C","E","F"]

Explanation

A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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The nurse is assessing a client with the diagnosis of left-sided heart failure. Which clinical finding should the nurse expect the client to experience?

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