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 B

Explanation

A) Incorrect- A blood pressure of 130/80 mm Hg is within a generally acceptable range for a person with diabetes and coronary artery disease. It may not directly indicate a complication related to the episodes of confusion. While blood pressure management is important for clients with diabetes and coronary artery disease, this particular blood pressure reading is not necessarily a significant finding in relation to the client's confusion.
B) Correct- Cervical spine stiffness or neck stiffness is a potential neurological symptom that can indicate a serious complication in a client with type 2 diabetes and coronary artery disease. The stiffness of the neck may be a sign of meningeal irritation, which can result from various conditions including infections such as meningitis. The client's medical history includes both type 2 diabetes and coronary artery disease, which are risk factors for cardiovascular events, including cerebrovascular accidents (strokes). Confusion can be a symptom of a stroke, and neck stiffness can be indicative of meningeal irritation secondary to a stroke or another neurological condition.
C) Incorrect- Dark yellow urine can be a sign of dehydration, which can be a concern for someone with diabetes. However, it is not directly related to episodes of confusion. Dehydration can cause various symptoms, but confusion is not typically associated with mild dehydration.
D) Incorrect- Excessive perspiration (diaphoresis) can occur for various reasons, including increased sympathetic nervous system activity, fever, anxiety, and physical activity. While it can be a symptom of certain complications, such as hypoglycemia (low blood sugar) or heart attack, it alone may not directly relate to the episodes of confusion in this client.

A. Repeat information to the client. B. Write information on a whiteboard. C. Talk loudly into the affected ear. D. Speak directly facing the client.

Correct Answer is D

Explanation

A) Incorrect- While repeating information can be helpful, it might not address the specific needs of a client with unilateral hearing loss. Simply repeating information may not improve comprehension if the client's hearing loss is in one ear.
B) Correct- Providing education for a client with unilateral hearing loss requires consideration of their specific communication needs. Writing information on a whiteboard allows the client to visually process the information, which can be particularly helpful for those with hearing loss in one ear. This method ensures that the client can access the information accurately and effectively.
C) Incorrect- Speaking loudly into the affected ear is not a recommended approach. It can be uncomfortable for the client and may not necessarily improve communication if the hearing loss is unilateral.
D) Incorrect- While speaking directly facing the client is a good practice in general, it may not fully address the communication challenges of someone with unilateral hearing loss. Providing visual information through writing is a more effective way to ensure the client receives the information accurately.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication?

Correct Answer is B

Explanation

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

Correct Answer is D

Explanation

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