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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Asking the provider to repeat another radiograph of the chest.
This option is not the most appropriate action in this scenario. While a chest radiograph may be useful in certain situations to assess for complications such as pneumothorax or pneumonia, it is not typically the first intervention for an asthma exacerbation with increased wheezing and decreased oxygen saturation. In this acute situation, the priority is to provide immediate treatment to alleviate the client's symptoms and improve oxygenation.
B. Increasing oxygen to maintain an oxygen saturation of 95% or greater in the client.
While maintaining adequate oxygenation is important, especially in a client with asthma exacerbation, it is not the first-line intervention in this scenario. Oxygen supplementation may be necessary, but the priority is to address the underlying bronchospasm causing the decreased oxygen saturation. Therefore, this option may be considered after initiating appropriate bronchodilator therapy.
C. Requesting the pharmacy to dispense 10 mL of dextromethorphan PO.
This option is not appropriate for managing an asthma exacerbation. Dextromethorphan is a cough suppressant and does not address the underlying bronchospasm characteristic of asthma exacerbations. In fact, suppressing cough may hinder the clearance of mucus and exacerbate respiratory distress. Therefore, this intervention is not indicated and may delay appropriate treatment.
D. Instructing respiratory therapy to administer a PRN albuterol aerosol.
This is the correct action in this scenario. Albuterol is a short-acting bronchodilator commonly used to relieve bronchospasm and improve airflow in clients experiencing asthma exacerbations. Administering albuterol via aerosolized inhalation helps to quickly deliver the medication directly to the airways, providing rapid relief of symptoms such as wheezing and improving oxygenation. Therefore, instructing respiratory therapy to administer a PRN albuterol aerosol is the most appropriate intervention to address the client's acute symptoms.
Correct Answer is C
Explanation
A. Constipation
Constipation is not typically associated with obstructive sleep apnea. However, sleep disturbances and certain medications used to manage OSA may indirectly contribute to constipation in some cases.
B. Nausea
Nausea is not a common symptom of obstructive sleep apnea. While sleep disturbances may affect gastrointestinal function in some individuals, nausea is not a typical manifestation of OSA.
C. Headache
One of the common findings associated with obstructive sleep apnea (OSA) is headache. This occurs due to the repeated episodes of apnea (cessation of breathing) during sleep, which leads to intermittent hypoxia (low oxygen levels) and subsequent cerebral vasodilation. The vasodilation can trigger headaches, often described as morning headaches, upon waking up. These headaches are typically frontal and may be accompanied by other symptoms such as fatigue and irritability.
D. Hypotension
Hypotension (low blood pressure) is not a typical finding in obstructive sleep apnea. In fact, individuals with OSA are more likely to have hypertension (high blood pressure) due to the effects of repeated apnea episodes on the cardiovascular system, such as increased sympathetic activity and arterial stiffness.
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