The nurse is caring for a client diagnosed with deep vein thrombosis who suddenly becomes short of breath, anxious, and restless.

The vital signs are: heart rate 130 beats/minute, respirations 42/minute, blood pressure 90/50, and pulse oximetry is 90%. An intravenous infusion of normal saline is running at 75ml/hr. The nurse elevates the head of the bed and applies nasal oxygen at 2L/min.

What action should the nurse take next?

Choice A rationale

Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.

Choice B rationale

Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.

Choice C rationale

Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.

Choice D rationale

Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.