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 B

Explanation

a. Creatinine 0.9 mg/dL: This creatinine level is within the normal range and is not an immediate priority for knee arthroplasty.

b. WBC count 20,000/mm3: An elevated white blood cell count suggests the presence of

infection or inflammation. In the context of knee arthroplasty, infection is a significant concern and requires immediate attention to prevent complications.

c. Potassium 3.8 mEq/L: This potassium level is within the normal range and is not an immediate priority for knee arthroplasty.

d. Hematocrit 40%: This hematocrit level is within the normal range and is not an immediate priority for knee arthroplasty. The elevated WBC count takes precedence as it suggests a

potential infectious process.

A. Serum chloride 99 mEq/L B. Serum calcium 10.5 mg/dL C. Serum potassium 5.2 D. Serum sodium 140 mEq/L.

Correct Answer is C

Explanation

a. Serum chloride 99 mEq/L: Serum chloride within the reference range is not an adverse effect of spironolactone.

b. Serum calcium 10.5 mg/dL: Serum calcium within the reference range is not an adverse effect of spironolactone.

c. Serum potassium 5.2: Spironolactone is a potassium-sparing diuretic, and an elevated serum potassium level is an adverse effect that requires monitoring. The nurse should assess for

hyperkalemia.

d. Serum sodium 140 mEq/L: Serum sodium within the reference range is not an adverse effect of spironolactone.

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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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