Pulmonary Embolism

For the client at risk for pulmonary embolism (PE), which assessment finding would indicate to the nurse that the client has a pulmonary embolism? Abrupt onset of dyspnea and apprehension. Significant bilateral wheezing. Slow increase in heart and respiratory rates. Cyanosis of the upper torso.

A. Rationale: Symptoms of pulmonary embolism have a sudden onset, and the dyspnea causes apprehension in the client. Increase in heart and respiratory rates with PE is abrupt, not slow. Cyanosis of the upper torso is associated with embolism of a central vein rather than the pulmonary vasculature. Bilateral wheezing is associated with asthma.

A client in skeletal traction suddenly develops right-sided chest pain and shortness of breath. Which intervention is priority for the nurse? Check for Homan's sign. Start oxygen per nasal cannula. Elevate the head of the bed 45 degrees. Administer the prescribed analgesic.

B Rationale: Right-sided chest pain and shortness of breath indicate the development of a pulmonary embolism. Oxygen is started to support gas exchange and tissue oxygenation. While elevating the head of the bed may support ventilation, it may be contraindicated by the type of skeletal traction. Homan's sign will provide information about venous thrombosis but is not the priority at this time. The analgesic is of lower priority than the oxygen and it may depress respirations.

The nurse is teaching a client who will be discharged home on enoxaprin (Lovenox) about self-care at home. Which statement by the client indicates understanding? "I will use a hard toothbrush and floss twice daily." "I will use an electric razor." I will report blurred vision." I will take aspirin for pain."

B. Rationale: Since enoxaprin is an anticoagulant, the client is taught to use an electric razor, use a soft toothbrush, and not to floss to prevent the chance of excess bleeding. Aspirin will increase bleeding potential. Blurred vision is not associated with anticoagulants.

The nurse selects the nursing diagnosis of decreased cardiac output for a client with a pulmonary embolism based on which findings? Client is alert and oriented. Decreasing urine output Bounding pedal pulses Positive bowel sounds

B. Rationale: The client with decreased cardiac output has compromised perfusion to all bodily organs. The signs and symptoms would include decreasing urine output, absent or weak pedal pulses, absence or weak bowel sounds, and a decreasing level of consciousness.

Prior to surgery, the nurse is teaching the client about pulmonary embolism. The nurse tells the client that the primary treatment is prevention. The client asks the nurse what steps can be taken to prevent this condition and the nurse responds with: (Select all that apply.) intravenous fluids for 4 days postoperatively. pulmonary artery wedge pressure monitoring. early ambulation after surgery. flexing of ankles postoperatively. external pneumatic compression boots.

C, D, E Rationale: Early ambulation and flexing the ankles or ROM exercises will help prevent venous stasis and pulmonary emboli. For some clients, the doctor may order external compression boots to promote circulation. While hydration is important, if the client is taking fluids well, there is no need to continue IV fluids for 4 days. Pulmonary artery wedge pressure monitoring is not a preventive measure, but a monitoring of the pressure in the lungs after an embolus has occurred.

The nurse administers which medication as part of pharmacological treatment aimed at prevention of pulmonary embolism? Aquamephyton (vitamin K) Streptokinase Enoxaparin (Lovenox) Protamine sulfate

C. Rationale: Administration of anticoagulants is an effective means of preventing pulmonary embolism. Thrombolytic drugs such as streptokinase are used to dissolve already formed clots. Vitamin K and protamine sulfate are used to facilitate clotting and counteract the effects of anticoagulants.

The nurse is caring for a client who is placed on strict bed rest. When planning care, the nurse initiates which action to prevent pulmonary emboli? Apply heating pad to both legs. Restrict fluids. Provide active ROM to the legs. Place a pillow under the knees.

C. Rationale: A basic preventive measure for the prevention of pulmonary emboli for the client on bed rest is to promote circulation by active ROM exercises. The nurse would keep the client well hydrated. Heat is not applied without a physician's order and placing a pillow under the knees promotes venous stasis and clot formation.

A 65-year-old client begins to have chest pain, decreasing oxygen saturation, and dyspnea after surgery. The nurse expects the physician to order which diagnostic test for a definitive diagnosis of pulmonary embolism? Electrolyte panel MRI Chest x-ray and ECG Complete blood count

C. Rationale: The symptoms and age of the client lead the nurse to conclude that the client may be experiencing a myocardial infarction or, since the client has had surgery, a pulmonary embolus. The chest x-ray is done to detect the embolus, and an ECG is done to rule out a myocardial infarction. An MRI is not done for either condition and, in any case, would take about 2 hours to complete; this client's symptoms indicate an emergency. Electrolyte panels and a complete blood count will not diagnose a pulmonary embolus or myocardial infarction.