The nurse is educating a client about the treatment options for a pulmonary embolism. Which of the following statements would require further teaching?

“I will be discharged on Warfarin so that a clot will not develop in the future."

"A Heparin infusion is going to keep the blood clot from getting bigger."

"The purpose of the Inferior Vena Cava (IVC) Filter is to prevent the development of DVTs."

"An embolectomy is a procedure to physically remove a blood clot."

Answer and Explanation

The Correct Answer is C

A. Warfarin is commonly prescribed for long-term anticoagulation to prevent future clot formation. This statement is correct and does not require further teaching.
B. A Heparin infusion does not dissolve existing clots but prevents them from enlarging and new clots from forming, making this statement accurate.
C. The purpose of the Inferior Vena Cava (IVC) filter is to trap emboli from deep vein thrombosis (DVT) before they reach the lungs, not to prevent DVT formation. This statement is incorrect and requires further teaching.
D. An embolectomy is a surgical procedure to remove a pulmonary embolism, making this statement correct.

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Correct Answer is B

Explanation

A. Providing health recommendations is important, but the immediate concern is addressing the client's fear.
B. Encouraging the client to express emotions allows the nurse to assess and provide appropriate emotional support.
C. Dismissing the client's fears can make them feel unheard and may increase anxiety.
D. Referring the client to the physician too soon may shut down communication and miss an opportunity for emotional support.

A. Encourage an increased intake of the client's favorite drink B. Continue to monitor daily weights and edema and document findings. C. Perform a head-to-toe assessment, including vital signs D. Check the record to determine code status

Correct Answer is C

Explanation

A. Encouraging increased fluid intake is incorrect. Clients with heart failure are at risk for fluid overload, and excessive fluid intake can worsen symptoms.
B. Simply monitoring and documenting findings is insufficient. A 2-pound weight gain in a short period suggests fluid retention and worsening heart failure, requiring further assessment and possible intervention.
C. Performing a head-to-toe assessment, including vital signs, is correct. The nurse should assess for worsening heart failure, including lung sounds (crackles), respiratory effort, blood pressure, and oxygen saturation, to determine if immediate interventions are needed.
D. Checking code status is not the priority. While knowing a client’s code status is important, the immediate concern is assessing for signs of fluid overload and potential decompensation.

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The nurse is educating a client about the treatment options for a pulmonary embolism. Which of the following statements would require further teaching?

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