PE/VTE (Med Surg)
6. Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)? A. Remain with the client and provide oxygen in a calm manner. B. Have the client breathe into a brown paper bag using pursed lips. C. Offer the client a mild sedative. D. Allow a family member to remain in the room.
Answer A The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen; remaining with the client in distress is appropriate. Rebreathing from a brown paper bag is an intervention that increases PaCO2 during hyperventilation, as in a panic attack; it will not provide needed oxygen. Sedation and/or allowing a family member to stay may calm the client, but will not improve oxygenation.
10. The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? (Select all that apply.) A. Dizziness and fainting B. Shortness of breath (SOB) worsening over the last 2 weeks C. Inspiratory chest pain D. Productive cough E. Pink, frothy sputum
Answer A,C Syncope, hypotension, and fainting are symptoms associated with PE. Sharp, pleuritic, inspiratory chest pain is also characteristic of PE. Sudden, not gradual, SOB occurs with PE. Productive cough is associated with infection; PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema; PE may cause hemoptysis.
2. Which client has the highest risk for developing a pulmonary embolism (PE)? A. A 25-year-old woman who frequently flies to different countries B. A 67-year-old man who works on a farm C. A 45-year-old man admitted for a heart attack D. A 23-year-old woman with a bleeding disorder
Answer A. People who engage in prolonged and frequent air travel are at higher risk for PE. A 67-year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs; if on prolonged bedrest, the client's risk is increased. PE is a clotting disorder, not a bleeding disorder.
8. The medical-surgical unit nurse should call the Rapid Response Team to assess which client? A. Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis B. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain C. Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94% D. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs
Answer A. The client with a diagnosed pulmonary embolism is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin; this indicates a significant decline in status and warrants activation of the Rapid Response Team. The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment; calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but has normal oxygen saturation. The client who was extubated 3 days ago requires ongoing monitoring or nursing intervention, but does not have evidence of acute deterioration or severe complications.
9. A client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? A. Teach the client to avoid using dental floss. B. Monitor the platelet count daily. C. Ensure adequate staffing for the unit. D. Notify radiology of an impending scan.
Answer B. Daily platelet counts are a safety priority in assessing for thrombocytopenia; heparin-induced thrombocytopenia is a possible side effect. Avoiding the use of dental floss is important during anticoagulation therapy, but it is not the priority. Adequate staffing and notifying radiology are not the priority.
5. When caring for a client with pulmonary embolism (PE), which arterial blood gas results does the nurse anticipate early in the course of the disease? A. pH 7.24, PaCO2 55 mm Hg, HCO3- 26 mEq/L, PaO2 56 mm Hg B. pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg C. pH 7.35, PaCO2 45 mm Hg, HCO3- 24 mEq/L, PaO2 80 mm Hg D. pH 7.47, PaCO2 35 mm Hg, HCO3- 30 mEq/L, PaO2 75 mm Hg
Answer B. Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). No compensation is present as the bicarbonate (HCO3-) (26 mEq/L) is normal, and hypoxemia is present, consistent with PE. A pH of 7.24 is acidotic, a partial pressure of arterial oxygen (PaO2) of 56 mm Hg reflects hypoxemia, and no compensation is present with a normal HCO3- (26 mEq/L); this blood would be found in a person in acute respiratory failure owing to hypoventilation and hypoxemia. A pH between 7.35 and 7.45, PaCO2 of 35 to 45 mm Hg, HCO3- of 22 to 26 mEq/L, and PaO2 greater than 75 mm Hg all reflect normal blood gas results. A pH of 7.47 and an HCO3- of 30 mEq/L are alkalotic, indicating metabolic alkalosis; a PaCO2 of 35 mm Hg is normal (indicating lack of compensation) and a PaO2 of 75 mm Hg is normal.
4. The nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about thrombolytic therapy? A. "You will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." B. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." C. "Once the health care provider orders warfarin (Coumadin), we will discontinue the intravenous heparin." D. "If bleeding develops, we will give you platelets to reverse the anticoagulant."
Answer B. The international normalized ratio (INR), a measurement of anticoagulation with warfarin, is in the therapeutic range between 2 and 3. Enoxaparin (Lovenox) is a low-molecular-weight heparin that is usually given by the subcutaneous route. Heparin and warfarin are overlapped until the INR is in the therapeutic range, then the heparin can be discontinued. Fresh-frozen plasma is used as an antidote for anticoagulant therapy, not platelets.
3. The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? A. Inadequate nutrition related to food-drug interactions and anticoagulant therapy B. Potential for infection related to leukocytosis C. Hypoxemia related to ventilation-perfusion mismatch D. Insufficient knowledge related to the cause of PE
Answer C Restoring adequate oxygenation and tissue perfusion takes priority when a client presents with a PE. Although nutrition must be addressed, priorities include airway, breathing, and circulation. The client has a leukocytosis related to lung inflammation; leukopenia places clients at risk for infection, but this is not the priority at this time. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability occur.
1. The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)? A. A client with diabetes and cellulitis of the leg B. A client receiving IV fluids through a peripheral line C. A client returning from an open reduction and internal fixation of the tibia D. A client with hypokalemia receiving potassium supplements
Answer C. Surgery and immobility are risks for deep vein thrombosis and PE. No evidence suggests that the client with diabetes has been immobile, which is a risk factor for PE; the client will be treated with antibiotics. For the client with a peripheral line, no evidence indicates a problem with the IV or with breakage of the catheter, which could lead to an air embolism. For the client with hypokalemia, no evidence reveals risk for PE; no immobility or hyper-coagulability is present.
7. The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal (GI) bleeding and an international normalized ratio (INR) of 6.9. For which factors should the nurse assess this client? A. Consumption of green leafy vegetables B. Prolonged exhalation C. Client has massaged his calves D. Use of aspirin or salicylates
Answer D. Use of aspirin and salicylates will prolong the INR and cause gastric irritation. Green leafy vegetables are high in vitamin K and would antagonize warfarin, resulting in a low(er) INR. A prolonged expiratory phase is typical in chronic obstructive pulmonary disease, not GI bleeding or a prolonged INR. Massaging the calves may present a risk for PE if deep vein thrombosis is present, but does not relate to GI bleeding and prolonged INR.