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.
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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Related Questions
Correct Answer is D
Explanation
a. "This test will inform your provider if you are anemic." Serum creatinine is not used to assess anemia. Anemia is often evaluated through tests like hemoglobin and hematocrit.
b. "This test will inform your provider if you have an infection." Serum creatinine is not a direct indicator of infection. It is primarily used to assess kidney function.
c. "This test will inform your provider if you have a thyroid disorder." Serum creatinine is not
used to evaluate thyroid function. Thyroid function is typically assessed through thyroid function tests.
d. "This test will inform your provider how your kidneys are functioning." This is the correct
response. Serum creatinine is a waste product that is filtered by the kidneys, and elevated levels may indicate impaired renal function.
Correct Answer is C
Explanation
A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.
B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.
The priority is to determine the client's immediate physiological status.
C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of
nausea and refusal of breakfast.
D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.
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