Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

Notify the healthcare provider.

Prepare a continuous heparin infusion per protocol.

Provide supplemental oxygen.

Bring the emergency crash cart to the bedside.

Answer and Explanation

The Correct Answer is C

Choice A reason: Notifying the healthcare provider is an important action, but not the first one. The nurse should prioritize interventions that address the client's immediate needs, such as oxygenation and circulation.

Choice B reason: Preparing a continuous heparin infusion per protocol is an appropriate action for preventing further clot formation and reducing the risk of recurrent pulmonary embolism, but it is not the first action. The nurse should first stabilize the client's condition before administering anticoagulant therapy.

Choice D reason: Bringing the emergency crash cart to the bedside is a prudent action, but not the first one. The nurse should prepare for possible cardiopulmonary resuscitation (CPR) in case of cardiac arrest, but should first attempt to prevent it by providing oxygen and other supportive measures.

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Correct Answer is D

Explanation

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

A. Alcohol consumption will not produce vascular changes. B. Weight management is promoted by taking daily walks for thirty minutes. C. Salt substitutes can help with maintaining a healthy diet. D. Blood pressure readings should be taken at noontime. E. Sodium intake can be regulated by rinsing canned foods in water. F. Uncontrolled hypertension can lead to renal damage.

Correct Answer is ["B","C","E","F"]

Explanation

Choice B is correct because weight management is an important factor in preventing and controlling hypertension. Taking daily walks for thirty minutes can help reduce weight and lower blood pressure.

Choice C is correct because salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Sodium intake is associated with increased blood pressure and should be limited to less than 2,300 mg per day.

Choice E is correct because sodium intake can be regulated by rinsing canned foods in water. Canned foods often contain high amounts of sodium as a preservative and rinsing them can remove some of the excess sodium.

Choice F is correct because uncontrolled hypertension can lead to renal damage. Hypertension can cause damage to the blood vessels and impair the function of the kidneys, leading to chronic kidney disease or failure.

Choice A is incorrect because alcohol consumption can produce vascular changes that increase blood pressure. Alcohol intake should be limited to no more than one drink per day for women and two drinks per day for men.

Choice D is incorrect because blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner.

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Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

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