A nurse is caring for a client diagnosed with pulmonary embolism. Which new-onset assessment finding should a nurse expect in a client diagnosed with a pulmonary embolism?

Tachypnea.

Wet cough.

Dull chest pain.

Episodes of apnea.

Answer and Explanation

The Correct Answer is A

A. Tachypnea: Tachypnea, or rapid breathing, is a common symptom of pulmonary embolism. It occurs as the body attempts to compensate for decreased oxygenation and increased carbon dioxide levels resulting from impaired blood flow to the lungs. Tachypnea helps to improve gas exchange by increasing ventilation.

B. Wet cough: A wet or productive cough may occur in conditions such as pneumonia or chronic bronchitis but is not typically associated with pulmonary embolism. Pulmonary embolism is more commonly characterized by symptoms such as dyspnea, chest pain, and tachypnea.

C. Dull chest pain: Chest pain associated with pulmonary embolism is often sharp and pleuritic, meaning it worsens with deep breathing or coughing. It may be described as stabbing or like a "knife-like" sensation. Dull chest pain is not a typical finding in pulmonary embolism.

D. Episodes of apnea: While severe cases of pulmonary embolism can lead to respiratory failure and apnea, it is not a common presenting symptom. Most clients with pulmonary embolism will exhibit tachypnea as a compensatory mechanism to maintain adequate oxygenation.

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Correct Answer is B

Explanation

A. People mistakenly think they are experiencing seasonal allergies: While seasonal allergies may share some symptoms with the common cold, such as nasal congestion and sneezing, they are caused by allergens rather than viruses. This factor does not directly contribute to the high communicability of the common cold.

B. The virus is spread by individuals who don't have symptoms: The common cold is highly communicable because individuals infected with the virus can spread it to others even before they develop symptoms or when they have mild symptoms. This makes it challenging to prevent the spread of the virus, as infected individuals may not realize they are contagious.

C. Hand washing is not effective against the cold virus: Hand washing is an effective measure for preventing the spread of the common cold virus. Proper hand hygiene can help reduce the transmission of the virus from contaminated surfaces to the nose and mouth.

D. Use of over-the-counter cold products reduces immune resistance: Over-the-counter cold products may help relieve symptoms of the common cold but do not directly affect immune resistance. However, reliance on symptomatic relief without taking precautions to prevent the spread of the virus can contribute to its communicability.

A. Document how many inches the tube has been inserted. B. Auscultate both lungs for the presence of breath sounds. C. Secure the endotracheal tube to prevent dislodgement. D. Obtain a chest x-ray to ensure correct tube placement.

Correct Answer is B

Explanation

A. Document how many inches the tube has been inserted: While documentation of the tube insertion depth is important, it is not the highest priority immediately after intubation. Ensuring proper placement and ventilation take precedence.

B. Auscultate both lungs for the presence of breath sounds: This is the priority action to confirm that the endotracheal tube is correctly placed in the trachea and that both lungs are being ventilated adequately. Absence of breath sounds on one side could indicate mainstem intubation or displacement of the tube.

C. Secure the endotracheal tube to prevent dislodgement: Securing the tube is important, but it should be done after confirming proper placement and ventilation.

D. Obtain a chest x-ray to ensure correct tube placement: While a chest x-ray is often performed after intubation to confirm tube placement, it is not the immediate priority. Auscultation provides more immediate feedback on the effectiveness of ventilation.

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A nurse is caring for a client diagnosed with pulmonary embolism. Which new-onset assessment finding should a nurse expect in a client diagnosed with a pulmonary embolism?

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Naxlex Comprehensive Predictor Exams

A clinic nurse is caring for a large number of clients diagnosed with the common cold. The nurse should recognize that which factor contributes to the high communicability of the common cold?

Correct Answer is B

Explanation

A nurse is caring for a client who experienced sudden onset of dyspnea, tachycardia, oxygen saturation of 82%, and has been intubated with an endotracheal tube. The nurse should perform which priority action immediately after the tube is placed in the trachea?

Correct Answer is B

Explanation

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