The nurse is assessing a client with a traumatic brain injury who is experiencing decorticate posturing.
Which assessment change indicates the client is improving?

Following major orthopedic surgery, a client presenting with sudden shortness of breath and tachycardia is highly suspicious for a pulmonary embolism. Knowledge of venous thromboembolism complications, diagnostic imaging protocols, and immediate stabilization techniques is necessary to prevent cardiovascular collapse and ensure respiratory support.

Choice A rationale: Computed tomography pulmonary angiography is the gold standard for diagnosing a pulmonary embolism. It allows for direct visualization of the pulmonary vasculature to identify arterial obstructions, which is essential for confirming the suspected condition in a post-operative patient.

Choice B rationale: A flat supine position can worsen respiratory distress by increasing the work of breathing and reducing lung expansion. Clients experiencing shortness of breath should be placed in a high-Fowler position to optimize ventilation and improve oxygenation.

Choice C rationale: Laboratory testing, including a complete blood count and coagulation studies, provides a baseline for the client's hematological status. These values are critical for planning the safe administration of therapeutic anticoagulation and monitoring for potential bleeding risks.

Choice D rationale: Obtaining venous access is a priority intervention to allow for the rapid administration of emergency medications or intravenous fluids. In the event of hemodynamic instability or the need for IV anticoagulants, established access is life-saving.

Choice E rationale: Continuous cardiac monitoring is necessary to track the client's heart rate and rhythm. Pulmonary embolism can cause right heart strain and dysrhythmias; monitoring allows the nurse to detect early signs of cardiac decompensation or worsening tachycardia.

Choice F rationale: Continuous oxygen saturation monitoring provides real-time data on the client’s respiratory status. Since pulmonary embolism impairs gas exchange, tracking saturation levels is vital to ensure that oxygen therapy is maintaining adequate systemic tissue perfusion.

Choice G rationale: Nurses cannot independently increase medication dosages, as this constitutes prescribing. Any changes to anticoagulant therapy, such as apixaban, must be ordered by a provider based on weight-based protocols and the severity of the thrombotic event.

Choice H rationale: Supplemental oxygen should be applied immediately to address the client's shortness of breath and potential hypoxemia. Increasing the concentration of inspired oxygen helps compensate for the ventilation-perfusion mismatch caused by the obstruction in the pulmonary arteries.

The management of indwelling urinary catheters requires strict adherence to evidence-based practices to prevent catheter-associated urinary tract infections. This scenario involves applying knowledge of aseptic technique, mechanical drainage patency, and the prevention of bacterial colonization within the urinary system.

Choice A rationale

Regular irrigation increases the risk of introducing pathogens into the sterile urinary tract by breaking the closed drainage system. Irrigation is only indicated for obstructions, such as blood clots, to maintain necessary catheter patency.

Choice B rationale

Daily perineal care should be performed with soap and water rather than antiseptic solutions. Antiseptics can irritate the urethral meatus and disrupt normal flora, potentially increasing the risk of bacterial overgrowth and subsequent infection.

Choice C rationale

Maintaining a prompt and unobstructed flow of urine is vital. Kinks or twists cause urine stasis, which allows bacteria to migrate upward into the bladder, significantly increasing the risk of developing a urinary tract infection.

Choice D rationale

Catheters should only be replaced based on clinical indications, such as obstruction or infection, not on a fixed schedule. Frequent, unnecessary changes increase the risk of urethral trauma and the introduction of exogenous microorganisms.