Nokea
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.
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An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
- A. Determine if the tube is kinked
- B. Ensure all connections are patent
- C. Listen to the client's lung sounds
- D. Suction the endotracheal tube
Correct Answer: C
Rationale: For an intubated client with hypoxia, the nurse should first assess for DOPE (displaced tube, obstruction, pneumothorax, equipment problems). Listening to lung sounds to confirm tube placement is the priority, as a displaced tube is the most common cause of hypoxia.
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.
A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?
- A. Assessing the client's platelet count
- B. Choosing an 18-gauge, 2-inch needle
- C. Not aspirating prior to injection
- D. Swabbing the injection site with alcohol
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously, requiring a smaller needle (e.g., 25"?26 gauge, 5/8 inch). An 18-gauge, 2-inch needle is inappropriate and could cause harm.
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?
- A. Hamburger and French fries
- B. Large chef's salad and muffin
- C. No selection, spouse brings pizza
- D. Tuna salad sandwich and chips
Correct Answer: B
Rationale: Warfarin inhibits vitamin K-dependent clotting factors. A large chef's salad with leafy greens high in vitamin K can interfere with warfarin's effectiveness, indicating a need for further education.
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.