N300 Exam 2: Pulmonary Embolus

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. Heparin is administered during throm- bolytic therapy, and the antidote is prota- mine sulfate and should be available to reverse the effects of the anticoagulant. 2. Firm pressure reduces the risk for bleeding into the tissues. ***3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. ***4. Invasive procedures increase the risk of tissue trauma and bleeding. ***5. Stool softeners help prevent constipation and straining, which may precipitate bleed- ing from hemorrhoids. TEST-TAKING HINT: Thrombolytic therapy is ordered to help dissolve the clot that resulted in the PE. Therefore, all nursing interventions should address bleeding tendencies. The test taker must select all interventions that are applicable in these alternative questions.

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

***1. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE. 2. Pulmonary emboli are not caused by athero- sclerosis; therefore, this is not an appro- priate discharge instruction for a client with pulmonary embolism. 3. Infection does not cause a PE;therefore, this is not an appropriate teaching instruction. 4. Pneumonia and flu do not cause pulmonary embolism. TEST-TAKING HINT: The test taker must know that deep vein thrombosis is the most common cause of pulmonary embolus and preventing dehydration is an important intervention. The test taker can attempt to eliminate answers by trying to figure out which disease process is appropriate for the intervention.

The client is suspected of having a pulmonary embolus. Which diagnostic test con- firms the diagnosis? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging (MRI).

***1. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis 2. ABGs evaluate oxygenation level, but they do not diagnose a pulmonary embolism. 3. ACXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE. 4. MRI is a noninvasive test that detects a deep vein thrombosis, but it does not diagnose a pulmonary embolus. TEST-TAKING HINT: The keys to answering this question are the words "confirms diagnosis." The test taker should eliminate "2" and "3" based on the fact that these are diagnostic tests used for many disease processes and conditions.

The nurse is preparing to administer medications to the following clients. Which medi- cation would 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. Hanging the heparin bag to a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

1. An INR of 2-3 is therapeutic; therefore, the nurse would administer this medication. 2. This is an elevated blood glucose level; there- fore, the nurse should administer the insulin. ***3. A normal PTT is 39 seconds; therefore, 58-78 is 1.5 to 2 times the normal value and is within the therapeutic range. A PTT of 98 means the client is not clotting and the medication should be held. 4. This is a normal blood pressure and the nurse should administer the medication. TEST-TAKING HINT: This question is asking the test taker to select a distracter that has assessment data that are unsafe for administering the medication. The test taker must know normal laboratory values to administer medication safely.

The nurse identified the client problem "decreased cardiac output" for the client diag- nosed 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.

1. Arterial blood gases would be included in the client problem "impaired gas exchange." ***2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output. 3. This would be appropriate for the client prob- lem "high risk for bleeding." 4. The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing. TEST-TAKING HINT: The test taker must think about which answer option addresses the problem of not getting enough blood out of the heart. Decreased blood to the extremities results in cyanosis and cold extremities.

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

1. The client needs oxygen, but the nurse can do something that will help the client before applying oxygen. ***2. 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. 3. This is needed, but it is not the first intervention. 4. Assessing the client is indicated, but it is not the first intervention in this situation. TEST-TAKING HINT: The test taker must select the option that will directly help the client breathe easier. Therefore, assessment is not the first intervention and option "4" can be eliminated as the correct answer. Oxygenation is important but positioning the client is the easiest and first intervention. The test taker should not immediately jump to conclusions. Always read the stem and think about what will help the client.

Which statement by the client indicates the discharge teaching for the client diagnosed with a pulmonary embolus 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 aspirin for my headache." 4. "I will wear a medic alert band at all times."

1. The client should use a soft-bristle toothbrush to reduce the risk of bleeding. 2. This is appropriate for a client with a mechan- ical valve replacement, not a client receiving anticoagulant therapy. 3. Aspirin, enteric-coated or not, is an anti- platelet, which may increase bleeding tendencies and should be avoided. ***4. The client should wear a medic alert band at all times so that if any accident or situa- tion occurs, the health-care providers will know the client is receiving anticoagulant therapy. TEST-TAKING HINT: This is a higher-level ques- tion in which the test taker must know that a client with a pulmonary embolus would be prescribed anticoagulant therapy on discharge from the hospital. If the test taker had no idea of the answer, however, the option stating "wear a medic alert band" would be a good choice because many disease processes require the client to take long-term medication and a health-care provider should be aware of this.

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 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.

1. The client would not be experiencing abnor- mal bleeding with this INR. 2. This is the antidote for an overdose of antico- agulant and the INR does not indicate this. ***3. A therapeutic INR is 2-3; therefore, the nurse should administer the medication. 4. There is no need to increase the dose; this result is within the therapeutic range. TEST-TAKING HINT: The test taker must know normal laboratory values; this is the only way the test taker will be able to answer this question. The test taker should make a list of laboratory values that must be memorized for successful test taking.

The client has just been 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.

1. The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants. 2. The client's respiratory system will be assessed, not the gastrointestinal system. 3. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE. ***4. Bed rest reduces metabolic demands and tissue needs for oxygen. TEST-TAKING HINT: The test taker must be aware of adjectives such as "oral" in option "1," which make this option incorrect. The test taker should apply the body system of the disease process to eliminate "2" as a correct answer.

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

1. These ABGs are within normal limits and would not warrant immediate intervention. 2. Occasional premature ventricular contractions are not unusual for any client and would not warrant immediate intervention. ***3. The normal pulse oximeter reading is 93%-100%. A reading of 90% indicates the client has an arterial oxygen level of around 60. 4. A urinary output of 800 mL over 12 hours indicates an output of greater than 30 mL/ hour, and this would not warrant immediate intervention by the nurse. TEST-TAKING HINT: This question is asking the test taker to select assessment data that are abnormal, unexpected, or life threatening in relationship to the client's disease process. A pulse oximeter reading of less than 93% indi- cates severe hypoxia and requires immediate intervention.

Which assessment data would support that the client has experienced a pulmonary embolus? 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.

1. This is a sign of a deep vein thrombosis, which is a precursor to a PE, but it is not a sign of a pulmonary embolism. ***2. The most common signs of a PE are sudden onset of chest pain when taking a deep breath and shortness of breath. 3. These are signs of a myocardial infarction. 4. These could be signs of pneumonia or other pulmonary complications, but not specifically a PE. TEST-TAKING HINT: The key to selecting "2" as the correct answer is sudden onset. The test taker would need to note "left-sided" in "3" to eliminate this as a possible correct answer, and "4" is nonspecific for a PE.

The client is diagnosed with a pulmonary embolus 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. If there are 20,000 units of heparin in 500 mL of D5W, then there are 40 units in each mL. 20,000 ÷ 500 = 40 units If 22 mL are infused per hour, then 880 units of heparin are infused each hour. 40 × 22 = 880 TEST-TAKING HINT: The test taker must know how to calculate heparin drips from two aspects: the question may give the mL/hr and the test taker has to determine units/hr or the question may give units/hr and the test taker has to determine mL/hr. Remember to learn how to use the drop-down calculator on the computer. During RN-NCLEX the test taker can request an erase slate