A nurse is caring for a client newly diagnosed with a pulmonary embolism (PE). Which of the following is the initial assessment finding in the client diagnosed with PE?
Dyspnea and anxiety.
Altered level of consciousness.
Wheezing in lung bases.
Increased pulse and respiratory rate.
The Correct Answer is A
Choice A rationale
The initial assessment finding in a client diagnosed with a pulmonary embolism (PE) is typically dyspnea and anxiety. This is because a PE can block blood flow in the lungs, leading to difficulty breathing (dyspnea). The sudden onset of this symptom can cause significant anxiety in the patient.
Choice B rationale
An altered level of consciousness is not typically an initial finding in PE. While severe cases can lead to decreased oxygen levels in the blood, causing confusion or loss of consciousness, these are not usually initial symptoms.
Choice C rationale
Wheezing in lung bases is not a typical initial finding in PE. Wheezing is more commonly associated with conditions that cause narrowing of the airways, such as asthma or COPD12.
Choice D rationale
While an increased pulse and respiratory rate can occur in PE due to the body’s attempt to compensate for decreased oxygen in the blood, they are not the most specific initial findings. Dyspnea and anxiety are more characteristic initial symptoms of PE12.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This response is more threatening than assertive. Threatening disciplinary action does not address the issue in a constructive manner and may create further conflict.
Choice B rationale
This response is more accusatory than assertive. It may make the colleague defensive and does not encourage open communication.
Choice C rationale
This response is more avoidant than assertive. It does not address the issue directly with the colleague and does not promote effective teamwork.
Choice D rationale
This response is assertive. It communicates the nurse’s feelings and needs clearly and respectfully, without blaming or threatening the colleague. It promotes open communication and effective teamwork.
Correct Answer is D
Explanation
Choice A rationale
Taking breaks outside in fresh air can help to clear the lungs of inhaled toxins to some extent. However, this measure alone is not sufficient to prevent inhalation exposure of job-related substances.
Choice B rationale
Consistently wearing a disposable paper mask can provide some protection against inhalable toxins. However, such masks may not be effective against all types of toxins and may not provide complete protection.
Choice C rationale
Keeping a fan blowing in the environment can help to disperse toxic substances and prevent them from becoming stagnant in the air. However, this measure alone may not be sufficient to prevent inhalation exposure, and in some cases, it could even spread the toxins more widely.
Choice D rationale
Wearing designated protective attire and devices when working with a toxic substance is the most effective measure to prevent inhalation exposure. This can include items such as respirators, which are designed to filter out specific toxins and protect the respiratory system.
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