The nurse reviews a note for a client who reports sharp chest pain that hurts worse when taking a deep breath and restlessness. The client's vital signs are Temperature 100 F (37.8 C), HR 104 BPM, RR 20 bpm with dyspnea, BP 114/62 mm Hg, and SpO2 90 percent on room air.
The nurse develops a plan of care to manage the client's suspected condition. Select six actions that would be appropriate for the nurse to include in the plan.

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..