A nurse is caring for a client who is postoperative following a colon resection.
For which of the following findings should the nurse monitor to identify a pulmonary embolus?
Swelling of lower extremity.
Burning sensation when voiding.
Sudden shortness of breath.
Purulent drainage at suture line.
The Correct Answer is C
Choice A rationale
Swelling of a lower extremity is a primary sign of a Deep Vein Thrombosis (DVT), the condition that predisposes a client to a pulmonary embolus (PE). A PE occurs when a thrombus (often from a DVT) embolizes to the pulmonary vasculature. Monitoring for DVT symptoms is essential, but the hallmark sign of the resultant PE is respiratory compromise.
Choice B rationale
A burning sensation when voiding (dysuria) is a classic symptom of a Urinary Tract Infection (UTI), due to irritation and inflammation of the bladder lining (cystitis) or urethra. This finding is entirely unrelated to a pulmonary embolus, which involves the cardiovascular and respiratory systems when an embolus lodges in the pulmonary arteries.
Choice C rationale
Sudden shortness of breath (dyspnea) is the most common and often dramatic symptom of a pulmonary embolus. This acute symptom arises from the occlusion of the pulmonary arteries by the embolus, which leads to a severe ventilation/perfusion (V/Q) mismatch and subsequent hypoxemia and rapid respiratory distress.
Choice D rationale
Purulent drainage at a suture line is the definitive local sign of a Surgical Site Infection (SSI), which indicates a bacterial invasion and inflammatory response in the wound bed. This finding relates to local wound healing complications and has no direct causal relationship with the development or signs of a pulmonary embolus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Protamine sulfate is the specific antidote for heparin overdose. It is a highly basic (alkaline) protein that forms a stable, inactive complex with the highly acidic heparin molecule, thereby neutralizing its anticoagulant effect, primarily its inhibition of Factor Xa and thrombin. The rapid action of protamine sulfate makes it crucial for reversing life-threatening bleeding associated with excessive heparin administration.
Choice B rationale
Vitamin K (phytonadione) is the antidote for warfarin overdose because it promotes the synthesis of active Vitamin K-dependent clotting factors (II, VII, IX, X) in the liver, reversing warfarin's inhibitory action. It is ineffective against heparin, which acts on existing clotting factors and antithrombin.
Choice C rationale
Glucagon is a pancreatic hormone used to treat severe hypoglycemia by stimulating hepatic glycogenolysis and gluconeogenesis, increasing blood glucose levels. It has no chemical or pharmacological effect on reversing the anticoagulant properties of heparin.
Choice D rationale
Ferrous sulfate is an oral iron supplement used to treat iron deficiency anemia by providing elemental iron necessary for hemoglobin synthesis in red blood cells. It does not interact with or neutralize heparin's anti-clotting mechanism.
Correct Answer is C
Explanation
Choice A rationale
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae, not a virus, and it is curable with appropriate antibiotic therapy, such as ceftriaxone. Informing the client that it is a virus and incurable provides false and misleading information, which could lead to non-adherence to treatment and continued transmission of the infection to sexual partners.
Choice B rationale
The presence of a chancre, or primary lesion, is the hallmark clinical manifestation of primary syphilis, an infection caused by the spirochete Treponema pallidum. Although both are sexually transmitted infections, gonorrhea typically presents with urethritis, cervicitis, or pharyngeal infection, not a chancre, which makes this assessment finding irrelevant to a diagnosis of gonorrhea.
Choice C rationale
Public health mandates and ethical responsibilities require the nurse to conduct thorough contact tracing for sexually transmitted infections like gonorrhea. Obtaining information about the client's recent sexual partners is vital so that they can be notified, tested, and treated, preventing further disease propagation and potential long-term complications, such as pelvic inflammatory disease.
Choice D rationale
A diaphragm is a barrier method primarily used for contraception and offers minimal protection against sexually transmitted infections like gonorrhea because it does not cover the external genitalia. The nurse should instruct the client on the consistent and correct use of condoms (male or female) as the most effective barrier method for preventing reinfection and transmission. 80mm.5pt.
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