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?

Begin oxygen therapy.

Start an IV infusion of lactated Ringer’s.

Initiate cardiac monitoring.

Administer IV morphine.

Answer and Explanation

The Correct Answer is A

a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.

b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.

c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.

d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.

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Correct Answer is A

Explanation

a.The statement "I will drink plenty of fluids after the test" indicates the client's understanding that hydration is important after the procedure, which is also a crucial aspect of post-procedure care. This response suggests the client understands the need to stay hydrated after ingesting barium, which helps eliminate the contrast material from the body and prevents constipation.

b. “I will expect my stool to be black after this procedure.”: The statement is related to the potential side effects of barium, but it does not address the pre-test instructions.

c. “I will expect a warm feeling when the dye is injected.”: This statement may relate to the sensation during the test but does not address the pre-test instructions.

d.while fasting may be required before the test, a clear liquid diet is not typically maintained for 24 hours prior to the procedure.

A. Decreased calcium level B. Decreased potassium level C. Elevated magnesium level D. Elevated sodium level

Correct Answer is B

Explanation

a. Decreased calcium level: NG tube drainage is more likely to result in hypokalemia (decreased potassium) than hypocalcemia (decreased calcium).

b. Decreased potassium level: NG tube drainage, which contains stomach contents, can lead to loss of potassium. Monitoring for hypokalemia is crucial as it can result in cardiac dysrhythmias.

c. Elevated magnesium level: NG tube drainage is not typically associated with an increase in magnesium levels.

d. Elevated sodium level: NG tube drainage may contribute to sodium loss, leading to hyponatremia, rather than hypernatremia.

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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?

Nursing Test Bank

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