Nokea
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
- A. Alteplase (Activase)
- B. Enoxaparin (Lovenox)
- C. Unfractionated heparin
- D. Warfarin sodium (Coumadin)
Correct Answer: A
Rationale: Alteplase is a thrombolytic indicated for large pulmonary embolisms with hemodynamic instability to rapidly dissolve the clot and restore circulation.
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A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
- A. Assess the cause of the agitation
- B. Reassure the client that he or she is safe
- C. Restrain the client's hands
- D. Sedate the client immediately
Correct Answer: A
Rationale: Determining the cause of agitation (e.g., pain, hypoxia, or anxiety) is the first step to address the underlying issue. Restraints or sedation may be needed but are not the initial action.
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes, PCO2: 28 mm Hg, Respiratory rate: 34, Feels frightened, PO2: 88 mm Hg, Can't catch my breath, SPO2: 88%, Blood pressure 158/92 mm Hg, Lungs have crackles. What action by the nurse is most appropriate?
- A. Call respiratory therapy for a breathing treatment
- B. Facilitate a STAT pulmonary angiography
- C. Prepare for immediate endotracheal intubation
- D. Prepare to administer intravenous anticoagulants
Correct Answer: B
Rationale: The client's symptoms and data (tachypnea, hypoxia, low PCO2, crackles, and anxiety) suggest a pulmonary embolism. STAT pulmonary angiography is the most appropriate action to confirm the diagnosis.
A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) mL
- A. 600 mL
- B. 660 mL
- C. 700 mL
- D. 750 mL
Correct Answer: B
Rationale: A tidal volume of 6 mL/kg is used to prevent lung injury. For a 242-pound (110 kg) client, 110 kg ? 6 mL/kg = 660 mL.
When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
- A. Avoid drinking alcohol
- B. Eat more omega-3 fatty acids
- C. Exercise on a regular basis
- D. Maintain a healthy weight
- E. Stop smoking cigarettes
Correct Answer: C,D,E
Rationale: Hormonal birth control increases clotting risk. Health promotion measures to reduce PE risk include regular exercise, maintaining a healthy weight, and smoking cessation, as these address immobility, obesity, and smoking-related risks.
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
- A. Assessing that the ventilator settings are correct
- B. Ensuring there is a bag-valve-mask in the room
- C. Obtaining personal protective equipment
- D. Planning to suction the client upon arrival to the room
Correct Answer: B
Rationale: A bag-valve-mask is critical for manual ventilation in case of ventilator failure, making it the priority to ensure client safety.