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car b. Notify the Rapid Response Team.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 on the cardiac monitor. What action by the nurse takes priority?

• Assess the clients lung sounds.
• Notify the Rapid Response Team.
• Provide reassurance to the client.
• Take a full set of vital signs.
• The blood clot interferes with perfusion in the lungs.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?

• Breathing so rapidly interferes with oxygenation.
• Maybe the client has respiratory distress syndrome.
• The blood clot interferes with perfusion in the lungs.
• The client needs immediate intubation and mechanical ventilation.
• Increase the heparin rate.

A normal PTT is 25-35 seconds, so this client's PTT is low A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds.What order should the nurse anticipate?

• Decrease the heparin rate.
• Increase the heparin rate.
• No change to the heparin rate.
• Stop heparin; start warfarin (Coumadin).

b. Platelet count: 82,000/L

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?

a. Hemoglobin: 14.2 g/dL

b. Platelet count: 82,000/L

c. Red blood cell count: 4.8/mm3

d. White blood cell count: 8.7/mm3

What is a normal platelet count value?

150,000-450,000

• Assess for other manifestations of hypoxia.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?

• Assess for other manifestations of hypoxia.
• Change the sensor on the pulse oximeter.
• Obtain a new oximeter from central supply.
• Tell the client to take slow, deep breaths.
• Interrupt the procedure to give oxygen.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?

• Ensure the client has adequate sedation.
• Find another provider to intubate
• Interrupt the procedure to give oxygen.
• Monitor the clients oxygen saturation.

C ~ When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?

• Determine if the tube is kinked.
• Ensure all connections are patent.
• Listen to the clients lung sounds.
• Suction the endotracheal tube.
• Provide frequent oral care per protocol.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

• Assess the client for sedation needs.
• Get family permission for restraints.
• Provide frequent oral care per protocol.
• Use nonverbal pain assessment tools.

• It will prevent ulcers from the stress of mechanical ventilation.

A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems.What response by the nurse is best?

• It will increase the motility of the gastrointestinal tract.
• It will keep the gastrointestinal tract functioning normally.
• It will prepare the gastrointestinal tract for enteral feedings.
• It will prevent ulcers from the stress of mechanical ventilation.
• Large chefs salad and muffin

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?

• Hamburger and French fries
• Large chefs salad and muffin
• No selection; spouse brings pizza
• Tuna salad sandwich and chips
• Strict vegetarian

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?

• Poor visual acuity
• Strict vegetarian
• Refusal to stop smoking
• Wants weight loss surgery
• Choosing an 18-gauge, 2-inch needle

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?

• Assessing the clients platelet count
• Choosing an 18-gauge, 2-inch needle
• Not aspirating prior to injection
• Swabbing the injection site with alcohol
• Alteplase (Activase)

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?

• Alteplase (Activase)
• Enoxaparin (Lovenox)
• Unfractionated heparin
• Warfarin sodium (Coumadin)

B, D, E

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)

• Client who had a reaction to contrast dye yesterday
• Client with a new spinal cord injury on a rotating bed
• Middle-aged man with an exacerbation of asthma
• Older client who is 1-day post hip replacement surgery
• Young obese client with a fractured femur

C, D, E

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.)

• Avoid drinking alcohol.
• Eat more omega-3 fatty acids.
• Exercise on a regular basis.
• Maintain a healthy weight.
• Stop smoking cigarettes.

A, B, C, E

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)

• Acknowledge the frightening nature of the illness.
• Delegate a back rub to the unlicensed assistive personnel (UAP).
• Give simple explanations of what is happening.
• Request a prescription for antianxiety medication.
• Stay with the client and speak in a quiet, calm voice.
• Prothrombin Time (PT/INR).

Following heparin treatment for a pulmonary embolism, a client is being discharged with a prescription for warfarin (Coumadin). In conducting discharge teaching, the nurse advises the client to have which diagnostic test monitored regularly after discharge?

• Perfusion scan.
• Prothrombin Time (PT/INR).
• Activated partial thromboplastin (APTT).
• Serum Coumadin level (SCL). Terms (18)

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