The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube.
Which finding requires immediate reporting?

This case involves a client showing signs of a suspected pulmonary embolism, including pleuritic pain and hypoxia. Managing this medical emergency requires prioritizing diagnostic imaging, maintaining oxygenation, ensuring vascular access for stabilization, and monitoring cardiac and respiratory status to prevent collapse.

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 blockages, which is essential for initiating the appropriate life-saving anticoagulation or thrombolytic therapy.

Choice B rationale

Placing a client with dyspnea and hypoxia in a flat supine position is contraindicated. This position increases the work of breathing and reduces lung expansion. The nurse should instead use a high-Fowler position to optimize ventilation-perfusion matching.

Choice C rationale

Obtaining venous access is a critical priority for any client with suspected pulmonary embolism. It ensures that emergency medications, such as intravenous heparin or fluids for hemodynamic support, can be administered immediately if the client's condition rapidly deteriorates or worsens.

Choice D rationale

Drawing laboratory tests like CBC and coagulation studies provides essential baseline data. CBC helps rule out infection or anemia, while coagulation studies like PT, PTT, and INR are required before starting systemic anticoagulants to ensure safe dosing.

Choice E rationale

Continuous cardiac monitoring is vital because a pulmonary embolism can cause acute right ventricular strain and lead to arrhythmias or sudden cardiac arrest. Early detection of heart rate changes or rhythm disturbances allows for rapid clinical intervention.

Choice F rationale

Given the client's current SpO2 of 90 percent, which is below the normal range of 95 to 100 percent, continuous monitoring is necessary. This ensures the nurse can titrate oxygen therapy and immediately identify further respiratory decline.

Choice G rationale

Nurses cannot independently increase medication dosages. Adjusting apixaban from 5 mg to 10 mg requires a specific provider order. Furthermore, in an acute suspected PE, parenteral anticoagulation like heparin is typically preferred over oral medications for faster effect.

Choice H rationale

Applying oxygen via nasal cannula or mask is an immediate priority to treat the client's hypoxia. Supplemental oxygen helps maintain cellular oxygenation and reduce the workload on the heart while further diagnostic testing and definitive treatments are arranged..

Pulmonary embolism disrupts the ventilation-perfusion ratio, leading to sudden hypoxemia and respiratory distress. Prioritizing interventions requires applying the airway, breathing, circulation framework. Knowledge of gas exchange and emergency protocols is necessary to stabilize the client and maintain systemic cellular oxygenation.

Choice A rationale

Oxygen administration is the priority to treat hypoxemia caused by the physiological dead space created by the embolism. Improving arterial oxygen saturation supports myocardial and cerebral function while reducing the workload of the right ventricle during obstruction.

Choice B rationale

Morphine acts as an analgesic and vasodilator which can reduce anxiety and preload. However, it does not address the primary physiological threat of impaired gas exchange. Breathing and oxygenation must be stabilized before managing pain or sedation.

Choice C rationale

Cardiac monitoring identifies arrhythmias and right-sided heart strain associated with pulmonary hypertension. While diagnostic, it is a secondary action that follows the restoration of oxygenation. Assessment tools should not delay the implementation of life-saving oxygen therapy.

Choice D rationale

Lactated Ringer's is used for volume expansion and electrolyte replacement. In pulmonary embolism, excessive fluid can worsen right ventricular failure and pulmonary edema. Circulatory support is important but remains secondary to correcting the immediate life-threatening respiratory deficit..