Exemplar 16.K: Pulmonary Embolism

The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. Which assessment finding caused the nurse to draw this conclusion? A) Body mass index (BMI) 35.8 B) Former cigarette smoker C) Blood pressure 132/88 mmHg D) Age 45 years

A) Body mass index (BMI) 35.8 Risk factors for the development of thrombus formation that could lead to a pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status as a former smoker, and blood pressure would not have as significant an impact on the development of a thrombus as the client's weight.

The nurse is caring for a child with a fractured femur who complains of sudden chest pain and difficulty breathing. Which test would the nurse question if it was ordered by the physician? A) D-dimer test B) V/Q scans C) Computerized tomography pulmonary angiography D) Magnetic resonance pulmonary angiography

A) D-dimer test Although V/Q scans, computerized tomography pulmonary angiography, and magnetic resonance pulmonary angiography are useful in diagnosing children with PE, the D-dimer test is not. Therefore, if the physician ordered a D-dimer test, the nurse may need to question this order.

The nurse is caring for a pregnant woman with a suspected pulmonary embolism without DVT. With regard to diagnostic tests to confirm the diagnosis what should the nurse anticipate being ordered for the client? Select all that apply. A) V/Q scan B) Computerized tomography pulmonary angiography C) Chest x-ray D) Non-stress test

A) V/Q scan B) Computerized tomography pulmonary angiography C) Chest x-ray For pregnant women who have a suspected pulmonary embolism without DVT, a chest x-ray should be performed. If the chest x-ray is normal, a V/Q scan should be performed, followed by computerized tomography pulmonary angiography if the V/Q scan is inconclusive. If the chest x-ray is abnormal, the computerized tomography pulmonary angiography should be performed first rather than the V/Q scan. A Doppler ultrasound and non-stress test may provide information of fetal wellbeing, but are not used to diagnose a PE.

The nurse is providing teaching about long-term anticoagulant therapy to a client recovering from a pulmonary embolism. Which client statement indicates that instruction has been effective? A) "I will expect bloody sputum when I brush my teeth." B) "I need to use a soft toothbrush and an electric razor to avoid injuries." C) "I need to eat a well-balanced diet with green salads." D) "I can expect to be bruised, since this is normal."

B) "I need to use a soft toothbrush and an electric razor to avoid injuries." Instruction on anticoagulant therapy should include the need to avoid injury, use a soft toothbrush, and use an electric razor. The client should avoid green salads because of the vitamin K content. The statements about bruising being normal and expecting bloody sputum mean the client is in need of additional instruction on anticoagulant therapy.

The nurse is providing care to several clients on a medical-surgical unit. Which client is at highest risk for a nonthrombotic pulmonary embolism (PE)? A) The client who is receiving intravenous pain medication B) The client who is postoperative from a femur fracture repair C) The client with a primary abdominal tumor D) The client who uses intravenous illicit drugs

B) The client who is postoperative from a femur fracture repair Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually occurs after fracture of long bone (typically the femur) releases bone marrow fat into the circulation. The other clients may be at risk for PE; however, they are incorrect choices for the most common cause of nonthrombotic pulmonary emboli.

The nurse is providing discharge instructions to an older adult client who is going home after having a total knee replacement. Which should the nurse include in the discharge teaching to decrease the client's risk for developing a thrombosis or pulmonary embolism (PE)? Select all that apply. A) Place pillows under the knees when in bed. B) Use compression stockings. C) Limit ambulation. D) Limit fluids. E) Continue with leg exercises.

B) Use compression stockings. E) Continue with leg exercises. A client being discharged after having orthopedic surgery is at increased risk for PE. The nurse should instruct the client to use compression stockings and continue with leg exercises to reduce the risk of deep vein thrombosis formation. The client should avoid placing pillows under the knees, be encouraged to ambulate, and be well hydrated unless another physiological condition exists that would necessitate a fluid restriction.

What increases after an embolus has become trapped in the pulmonary microvasculature? A) Perfusion B) Ventilation C) Dead space D) Alveolar surfactant

C) Dead space Dead space, or areas of the lung that are ventilated but not perfused, increases. Both perfusion and ventilation are decreased after a pulmonary embolism. Alveolar surfactant also decreases, increasing the risk for atelectasis (collapsed lung).

The nurse caring is caring for a client who is recovering from a hysterectomy. Which clinical manifestation supports that the client is experiencing a pulmonary embolism (PE)? A) Nausea B) Decreased urine output C) Dyspnea and chest pain D) Activity intolerance

C) Dyspnea and chest pain The most common symptoms of PE are dyspnea and pleuritic chest pain. Other manifestations include anxiety, cough, diaphoresis, hemoptysis, tachycardia, tachypnea, crackles, and a low-grade fever. Nausea, decreased urine output, and activity intolerance are not clinical manifestations of a PE.

The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism (PE). The nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? A) It is considered second-line treatment. B) Major hemorrhage is common. C) Heparin and warfarin (Coumadin) are usually initiated at the same time. D) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.

C) Heparin and warfarin (Coumadin) are usually initiated at the same time. Heparin and warfarin are usually initiated at the same time for the treatment of PE. Anticoagulant therapy is the standard first-line treatment of PE. While major hemorrhage is uncommon, bleeding may occur. Warfarin (Coumadin), not heparin, alters the synthesis of vitamin K-dependent clotting factors.

A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this client? A) Ineffective Tissue Perfusion B) Anxiety C) Impaired Gas Exchange D) Impaired Physical Mobility

C) Impaired Gas Exchange A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing impaired gas exchange. This would be the priority for the client at this time. The client may have ineffective tissue perfusion; however, this is not the priority. The client may be experiencing anxiety; however, this is not the priority at this time either. There is not enough information to determine whether the client is at risk for impaired mobility.

The nurse is planning care for a client with a pulmonary embolism. Which nursing action would assist with the client's decrease in cardiac output? A) Provide oxygen B) Keep protamine sulfate at the bedside C) Monitor pulmonary arterial pressures D) Assess for bleeding

C) Monitor pulmonary arterial pressures The client with a pulmonary embolism and decreased cardiac output is at risk for developing right heart failure. The nurse should monitor pulmonary arterial pressures. Oxygen would be appropriate for the client with impaired gas exchange. Assessing for bleeding and keeping protamine sulfate at the bedside would be appropriate for the client who is taking heparin.

The nurse is preparing to discharge a client recovering from a pulmonary embolism (PE). Which topics should the nurse to include in the teaching session? Select all that apply. A) Limit the use of over-the-counter medications B) Diet to include green leafy vegetables C) Symptoms of recurrence D) Anticoagulant administration schedule E) Resume normal activity level

C) Symptoms of recurrence D) Anticoagulant administration schedule The nurse should instruct the client in symptoms of bleeding or recurrence of a PE and the schedule for anticoagulation administration. The client being discharged after treatment for a PE needs to be instructed in avoiding all over-the-counter medications, avoiding green leafy vegetables because of vitamin K, and adhering to the physician's prescribed activity level.

A client scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. The nurse includes these instructions to decrease which postoperative complication? A) Infection B) Delayed wound healing C) Contractures D) Deep vein thrombosis

D) Deep vein thrombosis The best care for a pulmonary embolism (PE) is prevention. Since surgical clients have an increased risk of developing a PE postoperatively, instructions should include ways to encourage movement, such as leg exercises, and the need for pneumatic compression devices to maintain lower extremity circulation and prevent the development of a deep vein thrombosis. Exercises and pneumatic compression devices do not prevent infection, encourage wound healing, or prevent contractures.

The nurse is caring for a client who develops dyspnea and chest pain. Which diagnostic finding is consistent with a pulmonary embolism (PE)? A) Lack of infiltrates on chest x-ray B) Metabolic alkalosis on arterial blood gas C) Elevated CO2 level found on end-tidal carbon dioxide monitor D) Tachycardia and nonspecific T-wave changes on EKG

D) Tachycardia and nonspecific T-wave changes on EKG With PE, tachycardia and nonspecific T-wave changes occur on EKG. Pulmonary infiltration is common on a chest x-ray. The client with a PE will likely have respiratory alkalosis from rapid breathing, not metabolic alkalosis. The end-tidal CO2 (EtCO2) monitor will be decreased, not increased, due to rapid breathing.