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 A

Explanation

The correct answer is Choice A: "I will wear stockings with elastic tops."

Choice A rationale:

Wearing stockings with elastic tops can constrict blood flow in the legs, which is counterproductive for individuals with peripheral vascular disease. Compression stockings specifically designed for PVD are recommended, but these should be properly fitted and used according to medical advice.

Choice B rationale:

Avoiding crossing the legs at the knees is appropriate for individuals with PVD, as this can impede blood flow and worsen symptoms.

Choice C rationale:

Not going barefoot is important for clients with PVD, as it reduces the risk of injury and infection, which can be more serious due to compromised circulation.

Choice D rationale:

Using a thermometer to check the temperature of bath water is crucial for clients with PVD to avoid burns, since they may have decreased sensation in their extremities.

A. Eat foods that contain plenty of potassium. B. Take the medication at bedtime. C. Take aspirin for headaches. D. Expect some swelling in the hands and feet.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the client to consume foods rich in potassium because furosemide, a loop diuretic, can lead to potassium depletion. By consuming potassium-rich foods, the client can help maintain proper electrolyte balance. Common potassium-rich foods include bananas, oranges, potatoes, and leafy greens. It is crucial to prevent hypokalemia, as it can result in adverse effects such as cardiac dysrhythmias and muscle weakness.

Choice B rationale:

Taking furosemide at bedtime is not necessary, and it is not a standard instruction. Furosemide is usually taken in the morning to avoid nocturia, as it increases urine output. This option does not address the primary concern of managing pulmonary edema and the potential electrolyte imbalances associated with furosemide use.

Choice C rationale:

Taking aspirin for headaches is not relevant to the client's condition of pulmonary edema or the use of furosemide. This choice does not provide valuable guidance to the client and may lead to unnecessary medication use.

Choice D rationale:

Expecting swelling in the hands and feet is not an appropriate instruction for a client with pulmonary edema. The goal of furosemide therapy is to reduce edema and fluid retention, not to expect or tolerate swelling. This option does not contribute to the client's well-being and recovery.

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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?