After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

Administer IV opioids as needed for pain.

Teach how to use incentive spirometry.

Monitor for confusion and restlessness.

Observe for signs of increased bleeding.

Answer and Explanation

The Correct Answer is D

A. While pain management is important, it is not the most critical intervention compared to monitoring for bleeding, which can be life-threatening.

B. Teaching the client how to use incentive spirometry is important for improving lung function and preventing complications like atelectasis. However, in the context of a pulmonary embolism (PE), the immediate priority is to monitor for signs of increased bleeding due to the anticoagulant or thrombolytic therapy often used to treat PE. This is crucial to prevent potentially life-threatening complications.

C. Confusion and restlessness could indicate hypoxia, which is important to monitor in a PE patient. However, the immediate risk of bleeding due to anticoagulation therapy takes precedence.

D. Patients with a pulmonary embolism are typically treated with thrombolytic or anticoagulant therapy to prevent further clot formation and to help dissolve the existing clot. Anticoagulants significantly increase the risk of bleeding, making it crucial to monitor for signs of increased bleeding as a priority in the plan of care.

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Correct Answer is ["A","B","D"]

Explanation

The correct answer isa. Place a bedside commode next to bed.,b. Measure neurological vital signs every 4 hours.,d. Encourage family to participate in the client’s care.

Choice A rationale:

Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.

Choice B rationale:

Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.

Choice C rationale:

Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management.Routine suctioning can also cause discomfort and potential injury.

Choice D rationale:

Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process.Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.

Choice E rationale:

Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation.The effectiveness of music therapy can vary based on individual preferences.

A. Misplacing car keys. B. Difficulty performing familiar tasks. C. Losing sense of time. D. Problems with performing basic calculations. E. Becoming lost in a usually familiar environment. G. 0800

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale: Misplacing car keys occasionally is a common occurrence and may not necessarily indicate Alzheimer's disease. It can happen to anyone, especially when distracted or in a hurry.

Choice B rationale: Difficulty performing familiar tasks, such as cooking a meal or driving to a familiar location, is an early warning sign of Alzheimer's disease. It indicates changes in cognitive function.

Choice C rationale: Losing sense of time, such as not knowing the date, day of the week, or season, can be an early indicator of Alzheimer's disease. It reflects impairments in temporal orientation.

Choice D rationale: Problems with performing basic calculations, such as managing finances or following a recipe, are early signs of Alzheimer's disease. It shows a decline in cognitive abilities related to numbers and problem-solving.

Choice E rationale: Becoming lost in a usually familiar environment, such as getting disoriented in one's own neighborhood, is a significant early warning sign of Alzheimer's disease. It suggests spatial and memory impairments.

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After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

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Naxlex Comprehensive Predictor Exams

An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is ["B","C","D","E"]

Explanation

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