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","C","E"]

Explanation

The correct answer/s is Choice/s A, C, and E.

Choice A rationale: Obtaining the client’s tympanic temperature measurement is a crucial step. The client’s confusion and disorientation could be symptoms of an infection, such as a urinary tract infection or pneumonia. Infections in older adults can often present with atypical symptoms, including changes in mental status. Therefore, checking the client’s temperature can help identify if the client has a fever, which is a common sign of an infection.

Choice B rationale: While it’s always important to be aware of a client’s allergies, especially when administering medications, it doesn’t directly address the immediate concern of the client’s altered mental status. Therefore, it’s not the most appropriate action to take in response to the situation described.

Choice C rationale: Asking if the client is experiencing any pain with urination is relevant because urinary tract infections (UTIs) are common in older adults and can cause confusion and other changes in mental status. Pain during urination is a common symptom of a UTI.

Choice D rationale: Encouraging the intake of high protein foods is generally a good recommendation for older adults to maintain their strength and energy levels. However, it’s not directly related to the client’s current symptoms of confusion and disorientation.

Choice E rationale: Determining if the client has recently experienced a fall is important. Falls in older adults can lead to injuries, such as a head injury, which can cause confusion and other changes in mental status. Additionally, some medications used to treat pain after a fall can also contribute to confusion.

A. Call the pharmacy to obtain a client's next antibiotic dose. B. Observe a client's gait to determine the need for assistance. C. Bring a sterile chest drainage unit from central supply to the unit. D. Evaluate a client's urinary catheter for proper drainage.

Correct Answer is C

Explanation

A. This task is beyond the scope of practice for a UAP. Calling the pharmacy to obtain medications requires clinical judgment and understanding of medication administration, which is the responsibility of licensed nursing personnel. B. This task requires assessment skills, which are beyond the scope of practice for a UAP. Determining a client's need for assistance with mobility requires clinical judgment. C. This task is appropriate to delegate to a UAP. It involves transporting an item from one location to another, which does not require clinical judgment or assessment. D. This task requires assessment skills and clinical judgment, which are beyond the scope of practice for a UAP. Evaluating a client's urinary catheter involves assessing for patency and signs of complications, which should be done by a licensed nurse.

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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 client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

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