A nurse is caring for a client who develops a pulmonary embolism.
Which of the following interventions is the priority for the nurse to take?

Administer IV morphine.

Start an IV infusion of lactated Ringer's.

Begin oxygen therapy.

Initiate cardiac monitoring.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Administer IV morphine. Administering IV morphine may be necessary for pain management in a client with a pulmonary embolism. However, pain relief should not take precedence over ensuring the patient's oxygenation and cardiovascular stability. Oxygen therapy is the top priority to address hypoxia and prevent further deterioration. Once oxygenation is secured, pain management can be considered.

Choice B rationale:

Start an IV infusion of lactated Ringer's. Initiating an IV infusion of lactated Ringer's solution may be important for maintaining hydration and electrolyte balance in a patient with a pulmonary embolism. However, this is not the top priority when a client is at risk of or experiencing a pulmonary embolism. Ensuring oxygenation and cardiovascular stability takes precedence. Once the patient is stable, intravenous fluids can be administered if needed.

Choice D rationale:

Initiate cardiac monitoring. Initiating cardiac monitoring is important in assessing the patient's cardiac rhythm and identifying any dysrhythmias or changes that may occur due to the pulmonary embolism. While this is a vital step, it is not the highest priority when the client is in a state of hypoxia and respiratory distress. Oxygen therapy should be the first intervention to address the immediate threat to the patient's life.

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Correct Answer is B

Explanation

Choice A rationale:

Extreme thirst is not a typical finding in a client with hypokalemia. Hypokalemia is an electrolyte imbalance that can lead to symptoms like weakness and irregular heartbeats, but extreme thirst is not a direct result of low potassium levels.

Choice B rationale:

"Weak, irregular pulse" is the correct response. Hypokalemia can lead to cardiac arrhythmias, which may manifest as a weak, irregular pulse. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low levels can disrupt normal heart rhythms.

Choice C rationale:

Hyperactive bowel sounds are not typically associated with hypokalemia. Instead, you might expect diminished or absent bowel sounds in severe cases due to muscle weakness.

Choice D rationale:

Hyperactive reflexes are not typically associated with hypokalemia. Instead, hypokalemia can lead to muscle weakness and potentially even paralysis in severe cases.

A. "Fresh fruits are good to include with meals.”. B. "I will replace table salt with dried herbs.”. C. "I can have a cola drink twice a day.”. D. "I can eat frozen juice bars for a snack.”.

Correct Answer is C

Explanation

Choice A rationale:

"Fresh fruits are good to include with meals.”. Including fresh fruits with meals is an excellent choice for a heart-healthy diet. Fresh fruits are rich in essential vitamins, minerals, and fiber, which can help lower blood pressure and reduce the risk of heart disease.

Choice B rationale:

"I will replace table salt with dried herbs.”. This is a good choice for reducing sodium intake. Dried herbs can add flavor to food without the need for table salt, which is high in sodium. Lowering sodium intake is crucial for individuals with hypertension to manage their condition and maintain a heart-healthy diet.

Choice C rationale:

"I can have a cola drink twice a day.”. This choice is incorrect. Consuming cola drinks, which are high in sugar and caffeine, is not advisable for individuals with hypertension. High sugar intake can contribute to weight gain and high blood pressure, while caffeine can temporarily raise blood pressure. Clients with hypertension should limit or avoid soda consumption.

Choice D rationale:

"I can eat frozen juice bars for a snack.”. Frozen juice bars can be a healthier alternative to high-calorie, sugary snacks. However, the specific content of these bars should be considered. If they contain added sugars or high levels of sodium, it may not be the best choice. Clients with hypertension should focus on snacks that are low in added sugars and salt.

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A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?

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A nurse is caring for a client who develops a pulmonary embolism.
Which of the following interventions is the priority for the nurse to take?