A nurse is caring for a client who develops a sudden onset of dyspnea. Which of the following findings should the nurse expect if the client has a pulmonary embolus?
Expiratory rhonchi.
Petechiae over the lower extremities.
Hemoptysis.
Flattened neck veins.
The Correct Answer is C
Choice A rationale:
Expiratory rhonchi are typically associated with conditions such as chronic bronchitis or asthma but are not specific to pulmonary embolism.
Choice B rationale:
Petechiae over the lower extremities is not a characteristic finding in pulmonary embolism. Petechiae are tiny red or purple spots that appear due to bleeding under the skin and may be associated with other conditions like thrombocytopenia.
Choice C rationale:
The correct choice. Hemoptysis, which refers to coughing up blood, is a concerning finding in pulmonary embolism. It occurs due to the obstruction of blood flow in the pulmonary vasculature, leading to blood leaking into the lungs.
Choice D rationale:
Flattened neck veins are more likely to be observed in conditions associated with decreased venous return to the heart, such as hypovolemia or cardiac tamponade, and are not directly related to pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse's first priority in this situation should be to close the pinch clamp on the central venous catheter (CVC). This will prevent air from entering the client's vascular system and causing an air embolism, which can lead to serious complications. Once the clamp is closed, the nurse can then proceed with further assessments and interventions.
Choice B rationale:
Obtaining a prescription for stat ABGS (Arterial Blood Gas Studies) is not the first action the nurse should take in this situation. While ABGS may be relevant later to assess the client's respiratory status, the immediate concern is to prevent air embolism by closing the disconnected IV tubing.
Choice C rationale:
Placing the client in the left Trendelenburg position is not the first priority in this situation. The Trendelenburg position is used to increase venous return and is typically indicated in cases of hypotension or shock. Closing the clamp to prevent an air embolism should be the nurse's initial action.
Choice D rationale:
Checking the tubing for the placement of a locking adaptor is not the first action the nurse should take. While it is essential to ensure that the IV tubing is properly connected and secured, preventing the air from entering the CVC should take precedence in this urgent situation.
Correct Answer is C
Explanation
Choice A rationale:
Providing pin care when the client is 4 hours postoperative is not appropriate. The client has just undergone skeletal traction placement, and pin care is usually initiated after 24 hours to allow for initial wound healing.
Choice B rationale:
Removing the weights from the traction while repositioning the client in bed is unsafe and not recommended. The weights should remain in place to provide continuous traction and alignment for the fractured hip.
Choice C rationale:
Assessing the client's circulation every 4 hours is essential to monitor for any signs of impaired circulation, such as swelling, pallor, or decreased pulses. Early detection of circulatory compromise is critical to prevent complications like compartment syndrome.
Choice D rationale:
Requesting the client to perform ankle exercises on the affected extremity is not appropriate after skeletal traction placement. Ankle exercises could disrupt traction and hinder the healing process of the fractured hip.
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