Respiratory: Pulmonary Embolus

The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) L/day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccine.

1. Increase fluid intake to two (2) to three (3) L/day. Rationale: Increasing fluids will help increase fluid volume, which will in turn help prevent the development of DVT, the most common cause of PE. Why it's not the rest: PEs are not caused by atherosclerosis, and the diet recommendation is not appropriate for discharge teaching. Infection does not cause a PE, so avoiding large crowds is not appropriate teaching. Pneumonia and flu do not cause PE.

Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.

1. Keep protamine sulfate readily available. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered. Rationale: Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. Invasive procedures increase the risk of tissue trauma and bleeding. Stool softeners help prevent constipation and straining, which may precipitate bleeding from hemorrhoids. Why it's not the rest: Firm pressure reduces the risk for bleeding into the tissues.

The client is suspected of having a pulmonary embolus. Which diagnostic test suggests the presence of a pulmonary embolus and requires further investigation? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray (CXR). 4. Magnetic resonance imaging (MRI).

1. Plasma D-dimer test. Rationale: The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis. This result would require a CT or V/Q scan to then confirm the diagnosis. Why it's not the rest: An ABG evaluates oxygenation level. A CXR shows pulmonary infiltration and pleural effusions. An MRI is a noninvasive test that detects DVT; a CT or V/Q scan would be used.

The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases. 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

2. Assess skin color and temperature. Rationale: These assessment data monitor tissue perfusion, which evaluated for decreased cardiac output. Why it's not the rest: ABGs would be included in the client problem "impaired gas exchange." Checking for signs of bleeding is associated with the problem "high risk for bleeding." The client should not be put in the Trendelenburg position (head lower than the legs) because this would increase difficulty breathing.

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first? 1. Administer oxygen 10 L via nasal cannula. 2. Place the client in high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.

2. Place the client in high Fowler's position. Rationale: Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system. Why it's not the rest: The client needs O2 but the nurse can intervene to help the client before applying O2. A pulse oximeter reading is needed, but not the first intervention. Assessing the client is indicated, but it is not the first intervention.

Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

2. Sudden onset of chest pain and dyspnea. Rationale: The most common signs of a pulmonary embolism are sudden onset of chest pain and shortness of breath. Why it's not the rest: Calf pain is a sign of DVT, a precursor to a PE. Left-sided chest pain and diaphoresis are signs of a MI. Bilateral crackles and a low-grade fever could be signs of pneumonia or other pulmonary complications but not specifically a PE.

The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.

3. Administer the medication as ordered. Rationale: A therapeutic INR is 2 to 3, therefore the nurse should administer the medication. Why it's not the rest: The client would not be experiencing abnormal bleeding with this INR. Vitamin K is the antidote for an overdose of anticoagulant and the INR does not indicate this. There is no need to increase the dose.

The nurse is preparing to administer medication to the following clients. Which medication should the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hang the heparin bag on a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

3. Hang the heparin bag on a client with a PT/PTT of 12.9/98. Rationale: A normal PTT is 39 seconds, and for heparin to be therapeutic, it should be 1.5 to 2 times the normal value, or 58-79. A PTT of 98 indicated the client is not clotting and the medication should be held. Why it's not the rest: An INR of 2 to 3 is therapeutic, therefore the nurse would administer the warfarin. 218 mg/dL is an elevated BG, so the insulin should be administered. 112/82 is a normal BP, and the medication should be administered.

The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse? 1. The client's ABDs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions (PVCs). 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

3. The client's pulse oximeter reading is 90%. Rationale: The normal pulse oximeter reading is 93%-100%. A reading of 90% indicates the client has an arterial O2 level of around 60. Why it's not the rest: The ABGs are within normal range. Occasional PVCs are not unusual for any client and would not warrant immediate intervention. A urinary output of 800 mL is greater than 30 mL an hour and does not require immediate intervention.

Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspiring for my headache." 4. "I will wear a Medic Alert band at all times."

4. "I will wear a Medic Alert band at all times." Rationale: The client should wear a Medic Alert band at all times so that if any accident or situation occurs, the HCPs will know the client is receiving anticoagulant therapy. The client understands the teaching. Why it's not the rest: The client should use a soft-bristle toothbrush to reduce the risk of bleeding. Antibiotics would be appropriate for a client with a mechanical valve replacement, not a client receiving anticoagulant therapy. Aspirin, enteric-coated or not, is an antiplatelet which may increase bleeding tendencies and should be avoided.

The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bed rest.

4. Institute and maintain bed rest. Rationale: Bedrest reduces the risk of another clot becoming an embolus leading to a PE. Bedrest reduces metabolic demands and tissue needs for O2 in the lungs. Why it's not the rest: The IV anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants. The client's respiratory system will be assessed, not the GI system. A thoracentesis is used to aspirate fluid from the pleural space.

The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?

880 units/hr