A nurse is caring for a client who develops a pulmonary embolism.
Which of the following interventions is the priority for the nurse to take?
Maintain an IV infusion of lactated Ringer's.
Administer IV morphine.
Initiate cardiac monitoring.
Begin oxygen therapy.
The Correct Answer is D
Choice A rationale
Administering an IV infusion like Lactated Ringer's addresses potential hypovolemia or shock but is not the immediate priority for a client with pulmonary embolism (PE). PE primarily causes an obstruction of pulmonary blood flow, leading to ventilation-perfusion (V/Q) mismatch and resulting in hypoxemia, which must be addressed first.
Choice B rationale
IV morphine can alleviate the pleuritic chest pain and anxiety associated with a pulmonary embolism by depressing the central nervous system and reducing myocardial oxygen demand. However, managing pain is a secondary intervention to the life-threatening impairment of oxygenation.
Choice C rationale
Initiating cardiac monitoring is vital for detecting potential complications such as dysrhythmias or right heart strain secondary to increased pulmonary vascular resistance. Nevertheless, the immediate threat to life is profound hypoxemia due to the massive V/Q mismatch, making oxygen delivery paramount.
Choice D rationale
Beginning oxygen therapy is the priority intervention because a pulmonary embolism obstructs blood flow to the alveoli, causing a severe ventilation-perfusion (V/Q) mismatch and hypoxemia. Supplemental oxygen directly increases the PaO_2 and SaO_2, which are essential for maintaining adequate tissue oxygenation and preventing organ damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Enoxaparin sodium is a low molecular weight heparin (LMWH) that is administered subcutaneously, preferably into the anterolateral or posterolateral abdominal wall. Injection should be given at least two inches away from the umbilicus, surgical scars, and other lesions to ensure good absorption and minimize hematoma risk. This site has ample subcutaneous tissue for absorption.
Choice B rationale
Massaging the injection site following the administration of enoxaparin is contraindicated. The mechanical action of massage can increase the risk of bruising and hematoma formation at the injection site due to its anticoagulant properties, as it can disrupt local blood vessels and increase drug dispersion.
Choice C rationale
Subcutaneous injections typically utilize a shorter needle, often 5/8 inch, to deposit the medication into the subcutaneous tissue layer. A 1-inch needle is typically used for intramuscular (IM) injections, which would deliver the enoxaparin too deeply, potentially causing unnecessary discomfort and poor absorption.
Choice D rationale
Subcutaneous injections are typically administered with a 25-gauge or 27-gauge needle to minimize tissue trauma and pain. A 22-gauge needle is larger (has a wider lumen) and is typically used for thicker intramuscular injections or intravenous access, making it inappropriate for the intended subcutaneous route.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Polyuria is defined as excessive or abnormally large production or passage of urine, often greater than 2.5 liters in a 24-hour period. It is typically associated with conditions like diabetes mellitus (osmotic diuresis) or diabetes insipidus (deficiency of antidiuretic hormone). A routine urinary tract infection (UTI) usually presents with symptoms like increased frequency and urgency, but not necessarily an increase in total urine volume.
Choice B rationale
Urinary frequency is a classic symptom of a urinary tract infection (UTI), particularly cystitis (bladder infection). Inflammation and irritation of the bladder lining (urothelium) caused by the colonizing bacteria (often E. coli) lead to increased sensitivity and involuntary detrusor muscle contractions, resulting in a persistent, urgent, and frequent need to void small amounts of urine.
Choice C rationale
Dysuria, or painful and difficult urination, is a hallmark clinical manifestation of a urinary tract infection (UTI). The discomfort arises from the inflammatory response in the urethra and bladder lining (mucosa) as the body attempts to fight the bacterial invasion, causing a burning sensation, especially upon the passage of acidic urine over the inflamed tissues.
Choice D rationale
Dependent edema is the accumulation of excess interstitial fluid in the body's lower extremities due to the effect of gravity, often associated with systemic conditions like heart failure (elevated venous pressure) or renal disease (proteinuria/hypoalbuminemia). It is not a typical or expected finding directly associated with an uncomplicated, localized urinary tract infection (UTI).
Choice E rationale
Hematuria, the presence of blood in the urine, is a common finding in urinary tract infections (UTIs), especially cystitis. Inflammation and damage to the delicate capillary walls and mucosal lining of the bladder and lower urinary tract by the invading bacteria (e.g., E. coli) and the host's immune response can lead to the leakage of red blood cells into the urine.
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