Days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client had a pulmonary embolus. Which action should the nurse take first?
Notify the healthcare provider.
Prepare a continuous heparin infusion per protocol.
Provide supplemental oxygen.
Bring the emergency crash cart to the bedside.
The Correct Answer is C
Choice C is correct because providing supplemental oxygen is the first action that the nurse should take for a client who has a suspected pulmonary embolus. A pulmonary embolus is a life-threatening condition that occurs when a blood clot travels to the lungs and blocks the blood flow, causing hypoxia and respiratory distress. The nurse should administer oxygen to improve the client's oxygenation and prevent further complications.
Choice A is incorrect because notifying the healthcare provider is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. The nurse should notify the healthcare provider after providing supplemental oxygen and assessing the client's vital signs and symptoms.
Choice B is incorrect because preparing a continuous heparin infusion per protocol is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. Heparin is an anticoagulant that can prevent further clot formation and reduce the risk of recurrence, but it does not dissolve existing clots or improve oxygenation. The nurse should prepare a heparin infusion after obtaining a prescription from the healthcare provider and confirming the diagnosis with diagnostic tests.
Choice D is incorrect because bringing the emergency crash cart to the bedside is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. The emergency crash cart contains equipment and medications that can be used in case of cardiac arrest or other emergencies, but it does not address the immediate need of oxygenation. The nurse should bring the emergency crash cart to the bedside after providing supplemental oxygen and assessing the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A: Avoid salt substitutes. This client needs additional education, as salt substitutes may contain potassium, which can increase the risk of hyperkalemia in clients with coronary artery disease. The nurse should teach the client to use herbs, spices, or lemon juice to flavor food instead of salt or salt substitutes.
Choice B: Consume canned vegetables. This client needs additional education, as canned vegetables may contain sodium, which can increase the blood pressure and worsen coronary artery disease. The nurse should teach the client to choose fresh or frozen vegetables instead of canned ones.
Choice C: Include oatmeal for breakfast. This client does not need additional education, as oatmeal is a good source of soluble fiber, which can lower cholesterol and reduce the risk of atherosclerosis. The nurse should praise the client for this healthy choice.
Choice D: Identify foods with saturated fats. This client does not need additional education, as identifying foods with saturated fats is an important step to avoid them. Saturated fats can raise cholesterol and increase the risk of coronary artery disease. The nurse should teach the client to limit saturated fats to less than 10% of total calories per day.
Choice E: Walk 30 minutes per day. This client does not need additional education, as walking 30 minutes per day is a recommended physical activity for clients with coronary artery disease. Physical activity can improve blood circulation, lower blood pressure, and reduce stress. The nurse should encourage the client to walk at a moderate pace and consult with the healthcare provider before starting any exercise program.
Choice F: Keep a food diary. This client does not need additional education, as keeping a food diary is a helpful tool to monitor dietary intake and identify areas for improvement. The nurse should teach the client to record the type, amount, and time of food consumed, as well as any symptoms or feelings associated with eating.
Correct Answer is D
Explanation
Choice A: Increasing oxygen to 6 liters/minute is not an intervention that the nurse should implement, as this can worsen bronchospasm and hypoxia by reducing the hypoxic drive and causing carbon dioxide retention. This is a contraindicated choice.
Choice B: Calling for an Ambu resuscitation bag is not an intervention that the nurse should implement, as this is not indicated for a client who is conscious and breathing spontaneously. This is an overreaction choice.
Choice C: Instructing the client to lie back in bed is not an intervention that the nurse should implement, as this can increase respiratory distress and compromise airway clearance by reducing lung expansion and increasing abdominal pressure. This is another contraindicated choice.
Choice D: Administering a nebulizer treatment is an intervention that the nurse should implement, as this can deliver bronchodilators and anti-inflammatory agents directly to the airways and improve ventilation and oxygenation for this client. Therefore, this is the correct choice.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today