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:
A client who takes glyburide for type 2 diabetes mellitus is not at significant risk for developing digoxin toxicity. Glyburide is an antidiabetic medication and does not interact directly with digoxin.

Choice B rationale: Furosemide, a loop diuretic, can cause electrolyte imbalances such as hypokalemia (normal potassium levels: 3.5 to 5.0 mEq/L) and hypomagnesemia (normal magnesium levels: 1.7 to 2.2 mg/dL). These imbalances increase the sensitivity to digoxin and the risk of toxicity. Digoxin toxicity is associated with symptoms like nausea, vomiting, and arrhythmias. Furosemide's impact on electrolytes makes it a significant risk factor for digoxin toxicity.

Choice C rationale: Cimetidine, a histamine H2 receptor antagonist, can inhibit the metabolism of certain drugs by affecting liver enzymes. However, it does not significantly alter digoxin levels or increase the risk of toxicity. Normal liver enzyme levels include ALT (7 to 56 U/L) and AST (10 to 40 U/L). While cimetidine may interact with other medications, its effect on digoxin is minimal.

Choice D rationale:
A client who takes azelastine for allergic rhinitis is not at significant risk for developing digoxin toxicity. Azelastine is an antihistamine and does not interact directly with digoxin.

A. "I'll skip my coffee the morning of my test.”. B. "I'll get 8 hours of sleep the night before the test.”. C. "I will not smoke prior to my test.”. D. "I will expect to feel chest pain during this test.”.

Correct Answer is D

Explanation

Choice A rationale:

Skipping coffee on the morning of the exercise ECG stress test is a good idea as caffeine can affect heart rate and blood pressure, but it doesn't necessarily indicate the need for further instructions.

Choice B rationale:

Getting 8 hours of sleep the night before the test is a positive choice and promotes overall well-being, but it is not a specific indicator of needing further instructions for the test.

Choice C rationale:

Not smoking before the test is an appropriate action, as smoking can also affect heart rate and blood pressure during the test. However, it does not indicate a need for further instructions.

Choice D rationale:

Expecting to feel chest pain during an exercise ECG stress test is not correct and indicates a need for further instructions. Chest pain during the test can be a sign of cardiovascular issues and should be reported immediately.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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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?