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A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg. What action by the nurse is best?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Obtain a STAT chest X-ray
- C. Prepare to administer thrombolytic therapy
- D. Monitor the client's blood pressure every 15 minutes
Correct Answer: C
Rationale: The client's symptoms of anxiety, shortness of breath, chest pain, and hypotension suggest a pulmonary embolism, which can significantly impair gas exchange. Thrombolytic therapy is indicated for a large pulmonary embolism causing hemodynamic instability, as it can dissolve the clot and restore oxygenation.
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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.
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
- A. Assess for other manifestations of hypoxia
- B. Change the sensor on the pulse oximeter
- C. Obtain a new oximeter from central supply
- D. Tell the client to take slow, deep breaths
Correct Answer: A
Rationale: Pulse oximetry can sometimes produce normal readings despite hypoxia due to factors like poor peripheral perfusion. A thorough assessment for other signs of hypoxia (e.g., tachycardia, confusion) is the most appropriate action to confirm the client's status.
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?
- A. Poor visual acuity
- B. Strict vegetarian
- C. Refusal to stop smoking
- D. Wants weight loss surgery
Correct Answer: B
Rationale: A strict vegetarian diet high in vitamin K-rich foods can interfere with warfarin's anticoagulation effect, posing a barrier to consistent self-management.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
- A. Decrease the heparin rate
- B. Increase the heparin rate
Correct Answer: B
Rationale: A PTT of 25 seconds is below the therapeutic range (typically 1.5"?2.5 times the control value of ~30 seconds), indicating insufficient anticoagulation. Increasing the heparin rate is necessary to achieve therapeutic levels and effectively treat the pulmonary embolism.
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.