A client with a pulmonary embolism develops signs of severe hemoptysis and hypotension.
What should be the nurse's immediate priority?
Prepare the patient for stat diagnostic imaging.
Initiate high-dose anticoagulant therapy.
Monitor hemoglobin levels.
Administer intravenous fluids and high-volume oxygen via humidified NRB 10-15 L.
The Correct Answer is D
This scenario involves a pulmonary embolism complicated by hemodynamic instability and respiratory distress. Clinical management focuses on stabilization through fluid resuscitation to maintain cardiac output and high flow oxygenation to address hypoxia and ventilation perfusion mismatching.
Choice A rationale
Diagnostic imaging like CT angiography confirms embolism but is not prioritized during hemodynamic collapse. Immediate stabilization of blood pressure and oxygenation is necessary before moving a critically unstable patient to a radiology suite for testing.
Choice B rationale
Anticoagulation prevents further clot formation but is contraindicated in active severe hemoptysis. Administering heparin or similar agents would exacerbate bleeding, potentially leading to fatal hemorrhage or airway obstruction in an already unstable patient.
Choice C rationale
Hemoglobin monitoring tracks blood loss over time but does not address acute hypotension or hypoxia. Laboratory values lag behind clinical presentation, making this a secondary monitoring task rather than an immediate life saving intervention during crisis.
Choice D rationale
Hypotension and hemoptysis indicate shock and respiratory failure. Intravenous fluids expand intravascular volume to support preload, while high flow oxygen via non rebreather masks at 10 to 15 L per minute optimizes arterial oxygen saturation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Managing increased intracranial pressure requires applying knowledge of osmotic therapy, cerebral perfusion, and neurological positioning. Nurses must prioritize interventions that rapidly reduce cerebral edema while maintaining physiological stability and preventing herniation in patients with traumatic brain injuries or intracranial hypertension.
Choice A rationale
Pentobarbital is a barbiturate used for medically induced comas to reduce cerebral metabolic demand. While effective for refractory intracranial hypertension, it is typically a secondary or tertiary intervention rather than the immediate priority for an upward trend in pressure.
Choice B rationale
Mannitol is an osmotic diuretic that creates an osmotic gradient, pulling fluid from the cerebral interstitial space into the vascular compartment. This rapidly reduces brain volume and intracranial pressure, making it the first-line pharmacological priority for acute elevations.
Choice C rationale
Hyperventilation decreases PaCO2, causing cerebral vasoconstriction and reduced blood volume. However, excessive hyperventilation can cause cerebral ischemia. Increasing the rate to 20 should only be done under specific medical direction and is not the primary nursing priority here.
Choice D rationale
Proper positioning, such as head of bed elevation and avoiding neck flexion, facilitates venous drainage from the brain. While important, it is a supportive measure and less effective than osmotic diuretics for treating an acute, upward trend.
Correct Answer is C
Explanation
Educating a patient with atrial fibrillation requires applying knowledge of cardiac hemodynamics and the coagulation cascade. The nurse must focus on how ineffective atrial contractions lead to blood stasis, increasing the probability of clot formation and subsequent systemic embolization.
Choice A rationale
Atrial fibrillation does not directly cause hyperglycemia. While the stress of an acute arrhythmia might slightly elevate blood glucose due to cortisol release, it is not a primary complication or a major risk specifically linked to this rhythm.
Choice B rationale
Diabetic retinopathy is a microvascular complication resulting from chronic poor glucose control over many years. It is not exacerbated or caused by the onset of atrial fibrillation, which is a macrovascular and electrical conduction issue of the heart.
Choice C rationale
In atrial fibrillation, the atria quiver instead of contracting effectively, allowing blood to pool in the left atrial appendage. This stasis leads to thrombus formation; if a clot dislodges, it can travel to the brain.
Choice D rationale
Diabetic ketoacidosis is typically triggered by infection, insulin omission, or extreme physiological stress in Type 1 diabetics. While an arrhythmia is a stressor, the most specific and dangerous direct risk of atrial fibrillation remains systemic thromboembolism
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.