Clinical Manifestations of PE
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is caring for a client who has a pulmonary embolism.
The client reports sudden onset of dyspnea and chest pain.
What is the priority action by the nurse?
Explanation
The correct answer is choice A. Administer oxygen therapy.The priority action by the nurse for a client who has a pulmonary embolism is to increase perfusion and oxygenation by providing oxygen therapy.
This can help reduce hypoxemia, dyspnea, and chest pain.
Oxygen therapy can also prevent further clotting and pulmonary vasoconstriction.
Choice B is wrong because obtaining a chest x-ray is not the immediate action for a client with a pulmonary embolism.A chest x-ray can help confirm the diagnosis, but it is not a priority over oxygen therapy.
Choice C is wrong because starting an IV line is not the first action for a client with a pulmonary embolism.An IV line can facilitate the administration of fluids and medications, such as anticoagulants and thrombolytics, but it is not as urgent as oxygen therapy.
Choice D is wrong because giving morphine for pain is not the most important action for a client with a pulmonary embolism.Morphine can help relieve pain and anxiety, but it can also depress respiration and lower blood pressure, which can worsen the condition of the client.
Normal ranges for oxygen saturation are 95% to 100%.
Normal ranges for blood pressure are 120/80 mmHg or lower.
Normal ranges for heart rate are 60 to 100 beats per minute.Normal ranges for respiratory rate are 12 to 20 breaths per minute.
A nurse is reviewing the laboratory results of a client who has a suspected pulmonary embolism.
Which of the following findings indicates an increased risk for clot formation?
Explanation
The correct answer is choice A. Elevated D-dimer level.
D-dimer is a fibrin degradation product that is released when a blood clot is dissolved.A high level of D-dimer indicates an increased likelihood of blood clots, such as pulmonary embolism.A normal D-dimer level (below 500 ng/mL) can rule out pulmonary embolism in patients with low or moderate clinical pretest probability.
Choice B is wrong because decreased platelet count is not associated with pulmonary embolism.Platelet count may decrease after pulmonary embolism due to platelet activation and consumption, but it is not a risk factor for clot formation.
Choice C is wrong because low hematocrit level is not associated with pulmonary embolism.
Hematocrit level may decrease due to blood loss, hemolysis, or dilution, but it does not affect the risk of clot formation.
Choice D is wrong because high prothrombin time is not associated with pulmonary embolism.
Prothrombin time measures the time it takes for blood to clot in the presence of vitamin K-dependent factors.
A high prothrombin time indicates a deficiency or inhibition of these factors, which may increase the risk of bleeding, not clotting.
Normal ranges for D-dimer, platelet count, hematocrit, and prothrombin time may vary depending on the laboratory and the method used, but generally they are:
• D-dimer: <500 ng/mL
• Platelet count: 150-450 x 10^9/L
• Hematocrit: 36-48% for females, 40-54% for males
• Prothrombin time: 11-13 seconds
A nurse is teaching a client who has a history of deep vein thrombosis about prevention of pulmonary embolism.
Which of the following statements by the client indicates understanding of the teaching?
Explanation
The correct answer is choice A.“I should avoid smoking cigarettes.” Smoking cigarettes increases the risk of blood clots and deep vein thrombosis (DVT), which can lead to pulmonary embolism (PE) if the clot travels to the lungs.Smoking also damages the blood vessels and reduces oxygen levels in the blood.
Choice B is wrong because aspirin is not a recommended medication for preventing PE.Aspirin is a type of antiplatelet drug that prevents platelets from sticking together and forming clots, but it does not affect the clotting factors in the blood that are involved in DVT and PE.Anticoagulants, also known as blood thinners, are the preferred medications for preventing and treating DVT and PE, as they prevent further clot formation and decrease the chances of new clots.
Choice C is wrong because limiting fluid intake can increase the risk of dehydration, which can thicken the blood and make it more prone to clotting.Drinking plenty of water is important for preventing DVT and PE, especially when traveling or being immobile for long periods of time.
Choice D is wrong because wearing tight-fitting socks can restrict blood flow in the legs and increase the risk of DVT and PE.
A nurse is preparing to administer enoxaparin (Lovenox) to a client who has a pulmonary embolism.
Which of the following actions should the nurse take?
Explanation
Pinch the skin at the injection site.
This is because enoxaparin is a low molecular weight heparin that is administered subcutaneously, which means under the skin.Pinching the skin helps to create a fold of tissue that can be injected with the medication.Expelling the air bubble from the prefilled syringe is not necessary, as it helps to prevent leakage of the medication after injection.Injecting the medication into the deltoid muscle is wrong, as enoxaparin should not be given intramuscularly.Applying pressure to the injection site after administration is also wrong, as it can cause bruising or hematoma.
A nurse is monitoring a client who is receiving alteplase (Activase) for a pulmonary embolism.
Which of the following findings requires immediate intervention by the nurse?
Explanation
Hematuria.
Hematuria is the presence of blood in the urine and it indicates a bleeding complication from alteplase therapy.Alteplase is a thrombolytic drug that dissolves blood clots and restores blood flow, but it can also cause significant bleeding.
Hematuria requires immediate intervention by the nurse to stop the infusion and treat the bleeding.
Choice A is wrong because a blood pressure of 150/90 mmHg is not a contraindication for alteplase therapy.Alteplase should not be given to patients with severe uncontrolled hypertension, defined as systolic blood pressure >180 mmHg or diastolic blood pressure >110 mmHg.
Choice B is wrong because a heart rate of 100/min is not a sign of adverse reaction to alteplase therapy.Alteplase can cause cardiac arrhythmias, but they are usually transient and do not require treatment.
Choice C is wrong because a hemoglobin of 12 g/dL is within the normal range for adults (13.5-17.5 g/dL for males and 12-15.5 g/dL for females).
A low hemoglobin level may indicate bleeding or hemolysis from alteplase therapy and should be monitored closely.
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