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.
Dyspnea.
Dry cough.
Tachycardia.
The Correct Answer is B
The correct answer is choice B: Dyspnea.
Choice B rationale: Dyspnea, or difficulty breathing, is a potential indication of a recurrent pulmonary embolism and should be reported immediately. Early detection and intervention are crucial to prevent life-threatening complications.
Choice A rationale: Hypotension may be a concerning finding in postoperative clients, but it is not the priority for a client with a history of pulmonary embolism. Hypotension could be related to various factors like bleeding or anesthesia effects.
Choice C rationale: Dry cough may occur as a result of irritation or inflammation in the airway due to the surgical procedure or anesthesia. Although it should be monitored, it is not the highest priority in this situation.
Choice D rationale: Tachycardia can be a common postoperative finding due to pain, anxiety, or other factors. Although it should be monitored and addressed, it is not the most critical concern in this case. Dyspnea is more closely related to a possible pulmonary embolism and should be reported promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Determine any physical signs of injury.
Choice A rationale:
Asking the client for permission to take photographs is important for forensic evidence, but it should not be the first action. The nurse must first ensure the client’s immediate physical well-being.
Choice B rationale:
Providing community sexual assault support contacts is crucial for the client’s long-term support and recovery, but it is not the immediate priority in an emergency assessment.
Choice C rationale:
Documenting the client’s verbatim statements is essential for legal and medical records, but it should follow the initial physical assessment to address any urgent medical needs.
Choice D rationale:
Determining any physical signs of injury is the first priority. This ensures that any immediate medical needs are addressed, which is critical for the client’s safety and well-being.
Correct Answer is C
Explanation
The correct answer is c. Use an albuterol inhaler.
Choice A reason: Eating a meal before postural drainage is not recommended because it can cause discomfort, nausea, or vomiting due to the positions required for the procedure.
Choice B reason: Taking pancrelipase is important for aiding digestion in cystic fibrosis patients, but it is not specifically related to the preparation for postural drainage.
Choice C reason: Bronchodilators like albuterol are used before airway clearance techniques to open the airways, making it easier to clear mucus during postural drainage.
Choice D reason: While maintaining oral hygiene is important for overall health, it is not a preparation step for postural drainage.
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