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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Serum potassium: Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias.
b. Serum amylase: This is not directly related to furosemide therapy. Amylase is an enzyme associated with pancreatic and salivary function.
c. Serum triglyceride: Furosemide does not typically have a direct impact on serum triglyceride levels.
d. Serum cholesterol: Furosemide does not typically have a direct impact on serum cholesterol levels.
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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