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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.

A. Limit oral fluids to minimize labored breathing. B. Lie in a low Fowler’s position to promote lung expansion. C. Perform hourly incentive spirometry to inflate lungs and mobilize secretions. D. Perform pursed lip breathing to expel trapped carbon dioxide from the alveoli.

Correct Answer is C

Explanation

Choice A rationale
Limiting oral fluids is not the best action for a client with pneumonia and copious tracheobronchial secretions. Adequate hydration can actually help thin and loosen pulmonary secretions, making them easier to expel.
Choice B rationale
While lying in a low Fowler’s position can aid in lung expansion, it is not the priority action in this case. The client has copious tracheobronchial secretions, and the most effective way to mobilize these secretions is through incentive spirometry.
Choice C rationale
Performing hourly incentive spirometry can help inflate the lungs and mobilize secretions, which is particularly beneficial for a client with pneumonia who has copious tracheobronchial secretions. This is the priority action as it directly addresses the client’s issue of labored breathing due to excessive secretions.
Choice D rationale
Pursed lip breathing is a technique used primarily to slow the pace of breathing and can help maintain open airways longer. However, it is not the most effective method for mobilizing tracheobronchial secretions.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient immediately following endotracheal intubation. Which of the following actions should the nurse prioritize to assess the patient for complications?

Correct Answer is A

Explanation

A nurse is caring for a client diagnosed with pneumonia who has labored breathing and copious tracheobronchial secretions. What priority action should the nurse encourage with the client?

Correct Answer is C

Explanation

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