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 B
Explanation
A. Metabolic acidosis
Metabolic acidosis is characterized by a low pH (< 7.35) and a decreased bicarbonate level (< 22 mEq/L). In this scenario, the pH is low (7.22), but the bicarbonate level is elevated (28 mEq/L), which does not support a diagnosis of metabolic acidosis.
B. Respiratory acidosis
Respiratory acidosis occurs when there is an accumulation of carbon dioxide (PaCO2 > 45 mm Hg), leading to a decrease in pH (< 7.35). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), consistent with respiratory acidosis.
C. Metabolic alkalosis
Metabolic alkalosis is characterized by a high pH (> 7.45) and an elevated bicarbonate level (> 26 mEq/L). In this scenario, the pH is low (7.22), and the bicarbonate level is also elevated (28 mEq/L), which does not support a diagnosis of metabolic alkalosis.
D. Respiratory alkalosis
Respiratory alkalosis occurs when there is a decrease in carbon dioxide (PaCO2 < 35 mm Hg), leading to an increase in pH (> 7.45). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), which is not consistent with respiratory alkalosis.
Correct Answer is A
Explanation
A. 1 day after injection with a 10-mm area of redness and swelling:
This may suggest a positive reading, but induration size is the primary criterion for interpretation, not just redness and swelling.
B. 2 days after injection with a 5-mm area of redness and swelling:
Similar to option A, a 5-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. Again, without information on the size of the induration, we cannot determine if this reading is positive.
C. 4 days after injection with a 3-mm area of redness and swelling:
Once more, a 3-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. As with the previous options, the size of the induration is the critical factor for interpretation.
D. 5 days after injection with a 2-mm area of redness and swelling:
As with the other options, a 2-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. The presence and size of induration are essential for accurate interpretation.
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