A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

Place the client in high-Fowler's position.

Obtain the client's vital signs.

Administer heparin to the client.

Encourage the client to cough and deep breathe.

Answer and Explanation

The Correct Answer is A

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Correct Answer is A

Explanation

The correct answer is choice A, apply a motion sensor mat to the client's bed. This is an effective intervention to monitor the client's movements and prevent falls. The mat is placed under the bed sheet and will sound an alarm if the client tries to get out of bed.

Moving the overbed table away from the bed is not the correct answer because it does not prevent falls.
Raising all four side rails while the client is in bed is not the correct answer because it can cause the client to feel trapped and can lead to injuries if they try to climb over the rails.
Leaving the television on in the client's room is not the correct answer because it can be distracting and interfere with the client's sleep.

A. Diaphoresis B. Pupillary dilation C. Chest pain D. Hypotension

Correct Answer is D

Explanation

Opioid toxicity causes central nervous system and respiratory depression, which can lead to low blood pressure or hypotension.

Choice A. Diaphoresis is not correct because opioid toxicity does not cause excessive sweating. Diaphoresis can be a sign of opioid withdrawal or other conditions.

Choice B. Pupillary dilation is not correct because opioid toxicity causes miosis or pinpoint pupils due to the stimulation of the parasympathetic nervous system .

Choice C. Chest pain is not correct because opioid toxicity does not cause chest pain. Chest pain can be a sign of cardiac ischemia, pulmonary embolism, or other serious conditions.

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A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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