A nurse is reinforcing teaching for a client who presents with a pulmonary embolism. Which of the following information should the nurse provide?

Treatment is not needed if the client is asymptomatic.

Treatment is not needed if the pulmonary embolism is intermediate.

Treatment is not needed if the client is hemodynamically stable.

Treatment is needed for all clients who have a pulmonary embolism.

Answer and Explanation

The Correct Answer is D

A. Treatment is not needed if the client is asymptomatic.

Even asymptomatic pulmonary embolisms can lead to complications such as progression to symptomatic PE or development of chronic thromboembolic pulmonary hypertension. Therefore, treatment is necessary to prevent these complications.

B. Treatment is not needed if the pulmonary embolism is intermediate.

The severity of a pulmonary embolism is determined by various factors, including the size and location of the clot and the degree of obstruction in the pulmonary arteries. Intermediate-risk pulmonary embolisms still require treatment to prevent complications and reduce the risk of progression to a more severe or life-threatening condition.

C. Treatment is not needed if the client is hemodynamically stable.

Hemodynamic stability refers to the client's circulatory status and whether they are maintaining adequate blood flow to vital organs. While hemodynamically stable clients may not require aggressive interventions such as thrombolytic therapy or surgical embolectomy, they still require anticoagulant therapy to prevent further clot formation and reduce the risk of complications.

D. Treatment is needed for all clients who have a pulmonary embolism.

Pulmonary embolism (PE) is a serious and potentially life-threatening condition that requires prompt treatment. Regardless of the severity of symptoms or the client's hemodynamic stability, treatment is necessary to prevent complications and reduce the risk of recurrence. Treatment typically includes anticoagulant therapy to prevent further clot formation and may include additional interventions such as thrombolytic therapy or surgical interventions in certain cases.

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Correct Answer is B

Explanation

A. The spacer increases the amount of medication delivered to the oropharynx.

Spacers are designed to minimize the amount of medication deposited in the oropharynx (back of the throat) and reduce the risk of side effects such as oral thrush or hoarseness. The main purpose of using a spacer is to optimize the delivery of medication to the lungs.

B. The spacer increases the amount of medication delivered to the lungs.

When reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose inhaler (MDI) to treat asthma, the nurse should include the information that the spacer increases the amount of medication delivered to the lungs. Spacers help improve the delivery of medication from the MDI to the lungs by reducing the need for coordination between actuation of the MDI and inhalation. They also slow down the speed of the aerosolized medication particles, allowing more time for them to be inhaled into the lungs effectively.

C. Inhale rapidly when using the spacer with the MDI.

Inhaling rapidly may lead to improper inhalation technique and reduce the effectiveness of medication delivery to the lungs. Instead, the child should be instructed to inhale slowly and deeply to ensure that the medication reaches the lower airways.

D. Cover exhalation slots of the spacer with lips when inhaling.

Covering the exhalation slots of the spacer with lips during inhalation is not recommended. These slots are designed to allow the child to exhale freely and prevent buildup of pressure within the spacer. Encouraging the child to exhale into the spacer would hinder proper inhalation technique and could lead to decreased medication delivery to the lungs.

A. Administer IV morphine. B. Begin oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.

Correct Answer is B

Explanation

A. Administer IV morphine.

IV morphine may be indicated to relieve pain and anxiety associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

B. Begin oxygen therapy.

The priority intervention for a client who develops a pulmonary embolism is to begin oxygen therapy. Pulmonary embolism (PE) is a life-threatening condition characterized by a blockage in one or more of the pulmonary arteries, usually due to a blood clot. This blockage can lead to impaired gas exchange and decreased oxygenation of the blood, resulting in hypoxemia (low blood oxygen levels) and potentially leading to respiratory failure. Administering oxygen therapy promptly helps to improve oxygenation and support vital organ function. Therefore, it is the priority intervention to address the immediate respiratory distress associated with a pulmonary embolism.

C. Start an IV infusion of lactated Ringer's.

Intravenous fluid administration may be necessary to maintain hemodynamic stability and support perfusion in a client with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

D. Initiate cardiac monitoring.

Cardiac monitoring is important to assess for signs of cardiac compromise or dysrhythmias associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

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A nurse is reinforcing teaching for a client who presents with a pulmonary embolism. Which of the following information should the nurse provide?

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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