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 C

Explanation

a. Hyperactive bowel sounds: Shock is more likely to be associated with decreased bowel sounds rather than hyperactive bowel sounds.

b. Increased urine output: In the early stages of shock, there may be an increase in urine output as the body attempts to compensate. However, as shock progresses, renal perfusion decreases,

leading to decreased urine output.

c. Hypotension: Hypotension is a key indicator of shock. In shock, there is insufficient blood flow to meet the body's oxygen and nutrient needs, resulting in a drop in blood pressure.

d. Bradycardia: Shock typically leads to an increased heart rate (tachycardia) as the body tries to compensate for decreased cardiac output. Bradycardia is not a typical finding in the early stages of shock.

A. Neck vein distention B. Body weight C. Abdominal girth D. Blood pressure

Correct Answer is B

Explanation

a. Neck vein distention: Neck vein distention may indicate fluid overload, but it is not a direct measure of fluid losses.

b. Body weight: Monitoring body weight before and after hemodialysis provides a direct

measure of fluid losses. Hemodialysis removes excess fluid, and changes in body weight reflect fluid balance.

c. Abdominal girth: Abdominal girth may be affected by fluid accumulation but is not a direct measure of fluid losses during hemodialysis.

d. Blood pressure: While blood pressure may be influenced by fluid status, it is not a specific measure of fluid losses during hemodialysis. Body weight is a more direct indicator of fluid removal.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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