A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
Hypotension
Tachycardia
Dyspnea
Dry cough
The Correct Answer is C
A. Hypotension is a concern but may occur for various reasons and is not as immediately life-threatening as dyspnea.
B. Tachycardia can indicate a problem but is less urgent than respiratory distress.
C. Dyspnea is the priority as it may indicate a recurrence of pulmonary embolism or another life-threatening respiratory issue.
D. A dry cough is a less urgent symptom and does not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fibrinogen level: Fibrinogen is involved in clot formation but is not used to monitor warfarin.
B. INR: INR reflects the client’s clotting tendency and is essential for determining the appropriate warfarin dose. Therapeutic INR ranges typically vary based on the indication (e.g., 2.0–3.0 for atrial fibrillation).
C. Platelet count: Important for assessing bleeding risk, but it does not measure warfarin's efficacy.
D. aPTT: Used to monitor heparin therapy, not warfarin.
Correct Answer is D
Explanation
A. A face shield is unnecessary unless there is a risk of splashing.
B. Masks are not needed for C. difficile, as it is not spread through airborne transmission.
C. Alcohol-based hand rubs are ineffective against C. difficile spores; handwashing with soap and water is required.
D. Contact precautions for C. difficile require the nurse to remove the protective gown and gloves inside the client's room to prevent contamination of outside areas.
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