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 reason: 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 reason: 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 reason: 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 reason: 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 C
Explanation
Choice A reason: Monitoring indwelling urinary catheter and measure strict intake and output is not an action that the nurse should immediately take, as this is not relevant or urgent for a client who may have had a stroke. This is a distractor choice.
Choice B reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an action that the nurse should immediately take, as this is a preventive measure that does not address the acute problem of impaired cerebral perfusion. This is another distractor choice.
Choice C reason: Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an action that the nurse should immediately take, as this can prepare the client for potential administration of tissue plasminogen activator (tPA), which can dissolve blood clots and restore blood flow to the brain if given within 4.5 hours of stroke onset. Therefore, this is the correct choice.
Choice D reason: Maintaining elevated positioning of the dependent joints on affected side is not an action that the nurse should immediately take, as this can worsen edema and impair circulation in the affected limbs. The recommended position is to keep them at or below heart level. This is another distractor choice.
Correct Answer is D
Explanation
Choice D reason: frequent exposure to sunlight is the most significant environmental factor when planning care for a client with osteomalacia. Osteomalacia is a condition in which the bones become soft and weak due to inadequate mineralization, often caused by vitamin D deficiency. Vitamin D is essential for calcium absorption and bone health, and it can be synthesized by the skin when exposed to sunlight. The nurse should encourage the client to get at least 15 minutes of sunlight per day or take vitamin D supplements as prescribed.
Choice A reason: quiet, calm surroundings are not a specific environmental factor for a client with osteomalacia. Quiet, calm surroundings may help reduce stress and promote relaxation, but they do not affect bone mineralization or vitamin D synthesis.
Choice B reason: stimulating sounds and activity are not a specific environmental factor for a client with osteomalacia. Stimulating sounds and activity may help improve mood and cognition, but they do not affect bone mineralization or vitamin D synthesis.
Choice C reason: cool, moist air is not a specific environmental factor for a client with osteomalacia. Cool, moist air may help relieve respiratory symptoms or allergies, but it does not affect bone mineralization or vitamin D synthesis.
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