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 C

Explanation

Clients with a left-sided stroke will have neurological deficits on the right side of the body, including paralysis or weakness. Impaired speech, language, and cognition are also possible. Blood pressure, temperature, and laboratory results may be affected by the stroke, but they are not specific to a left-sided stroke.

Option A, "Blood pressure," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.

Option B, "Temperature," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.

Option D, "Laboratory results," is incorrect because they may be affected by the stroke, but they are not specific to a left-sided stroke.

A. A client who has Clostridium difficile and has liquid stools B. A client who had abdominal surgery 2 days ago and the incision line is separating C. A client who has a chronic tracheostomy and is intermittently coughing up clear sputum D. A client who fell 12 hr ago and reports pain as 4 on a scale of 0 to 10

Correct Answer is B

Explanation

The correct answer is choice B, a client who had abdominal surgery 2 days ago and the incision line is separating. This client requires immediate attention as a separating incision can indicate wound dehiscence or evisceration, which are surgical emergencies. Choice A is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention. Choice C is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition. Choice D is incorrect because the client fell 12 hours ago and reports pain as 4 on a scale of 0 to 10, which indicates a low level of pain.

Choice A: A client who has Clostridium difficile and has liquid stools is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention.

Choice C: A client who has a chronic tracheostomy and is intermittently coughing up clear sputum is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition.

Choice D: A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 is incorrect because the level of pain is low and does not require immediate attention.

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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

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Explanation

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