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 C

Explanation

A) Incorrect- Furosemide is a loop diuretic used to treat conditions such as edema and hypertension. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
B) Incorrect- Low-dose aspirin is often used for its antiplatelet effects to prevent cardiovascular events. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
C) Correct- Allopurinol is a medication used to treat gout by reducing the production of uric acid in the body. However, allopurinol can also increase the risk of forming calcium oxalate kidney stones, which is the type of kidney stone mentioned in the client's history. Calcium oxalate stones are the most common type of kidney stone, and they are composed primarily of calcium and oxalate. In this case, the client has a history of gout and is prescribed allopurinol. The nurse should bring the client's prescription for allopurinol to the healthcare provider's attention because

it has the potential to contribute to the formation of kidney stones, which could exacerbate the client's existing condition.
D) Incorrect- Enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and heart failure. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.

A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C). B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7. D. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg.

Correct Answer is A

Explanation

A) Correct- Viral meningitis is an inflammation of the meninges (the protective membranes surrounding the brain and spinal cord) caused by a viral infection. While it can be serious, it is generally less severe than bacterial meningitis. Monitoring the client's temperature is an important aspect of care, as changes in temperature can indicate the progression of the illness or the effectiveness of interventions. A temperature increase from 101°F to 102°F is a subtle change but may still require close monitoring and symptom management. The practical nurse (PN) is capable of monitoring vital signs, including temperature, and reporting any changes to the registered nurse (RN) or healthcare provider. It is within the PN's scope of practice to assess and report changes in vital signs and general condition. The other scenarios involve more complex clinical situations that may require the expertise of registered nurses.
B) Incorrect- Myxedema coma is a severe form of hypothyroidism and is considered a medical emergency. Managing and assessing a client with myxedema coma requires advanced assessment, critical thinking, and interventions that are typically within the scope of registered nurses.
C) Incorrect- Diabetic ketoacidosis (DKA) is a complex condition that requires frequent monitoring of blood glucose levels, electrolytes, vital signs, and assessment of the level of consciousness. The change in the Glasgow Coma Scale score indicates a neurological deterioration that requires immediate attention and intervention, making it suitable for a registered nurse.
D) Incorrect- A subdural hematoma is a serious neurological condition that requires close monitoring of vital signs and neurological status. The change in blood pressure indicates a potential change in intracranial pressure and should be managed by registered nurses with expertise in neurological care.

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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

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Correct Answer is C

Explanation

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Explanation

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