What did you learn??? Pulmonary Embolism

A nurse is auscultating the lungs of a postpartum client and notices crackles and some dyspnea. The client's respiratory rate is 12 breaths/minute; she appears in some distress. What complication should the nurse suspect based on these data? pulmonary edema hemorrhage infection fluid volume deficit

Any change in the respiratory rate of a postpartum woman might indicate pulmonary edema, atelectasis, or pulmonary embolism and must be reported. Lungs should be clear upon auscultation.

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? Nonproductive cough and abdominal pain Hypertension and lack of fever Bradypnea and bradycardia Chest pain and dyspnea

As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism.

From which one of the following sites is a fatal pulmonary thromboembolism most likely to originate? The endocardium over an acute myocardial infarction Deep vein thrombophlebitis of the leg An atherosclerotic plaque in the aorta The hepatic vein in chronic passive congestion of the liver

Deep vein thrombosis (DVT) may be a precursor to pulmonary embolism. The risk of pulmonary embolism emphasizes the need for early detection and treatment of DVT.

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? Myasthenia gravis Type 1 diabetes mellitus Extreme anxiety Opioid overdose

Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? compartment syndrome fat embolism infection Volkmann's ischemic contracture

Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.

A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients? Passive range of motion exercises for the upper and lower extremities Early ambulation and the use of compression stockings Incentive spirometry and deep breathing and coughing exercises Maintenance of SpO2 levels ≥90% using supplementary oxygen

For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client? Excess fluid volume Acute pain Ineffective breathing pattern Activity intolerance

Ineffective breathing pattern takes priority for a client with a pulmonary contusion with a pulmonary embolism. The objective of immediate management is to restore and maintain cardiopulmonary function. After an adequate airway is ensured and ventilation is established, examination for shock and intrathoracic and intra-abdominal injuries is necessary. Fluid volume, pain, and activity intolerance are not priority concerns.

A client recently had surgery for a hip fracture. Which nursing intervention would be most effective for preventing pulmonary emboli in this client? Prevention of the development of a deep vein thrombosis Use of oxygen and incentive spirometer following surgery Monitor hematocrit and hemoglobin levels Encourage increase fluid intake

Prevention of the development of a deep vein thrombosis Almost all pulmonary emboli are thrombi that arise from deep vein thrombosis in the lower and upper extremities. The presence of thrombosis in the deep veins of the legs or pelvis often is unsuspected until an embolism occurs.

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus? Tense and relax muscles in the lower extremities. Wear tight-fitting clothing. Consume the majority of daily fluid intake prior to bed. Begin estrogen replacement.

Tense and relax muscles in the lower extremities Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin? Report any incident of bloody urine, stools, or both. Administer calcium supplements. Assess for hypokalemia. Assess for clubbing of the fingers.

The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both. Clients taking enoxaparin will not need to take calcium supplements or have potassium imbalances related to the medication. The clubbing of fingers may occur with chronic pulmonary diseases.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? nausea or vomiting abdominal pain or diarrhea hallucinations or tinnitus light-headedness or paresthesia

The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

A client recovering from a pulmonary embolism is receiving warfarin. To counteract a warfarin overdose, the nurse should administer heparin. vitamin K1 (phytonadione). vitamin C. protamine sulfate. heparin.

Vitamin K1 is the antidote for a warfarin overdose. Heparin is a parenteral anticoagulant. Vitamin C isn't an antidote. Protamine sulfate is the antidote for heparin. I remember this by thinking of the Vitamin War (VIT k & WARfarin

The nurse is caring for four clients. Select the client at risk for the development of a pulmonary embolism. A 36-year-old female smoker with an intrauterine device (IUD) An 80-year-old female client with diabetes A 32-year-old male with viral pneumonia A 62-year-old male who is postoperative for repair of a fractured femur

A client with surgery to the lower extremities is at higher risk for the development of deep vein thrombosis that could lead to a pulmonary embolism. There is increased risk for pulmonary embolism among users of oral contraceptives, particularly in women who smoke, but not with the use of IUD.

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient? Perfusion exceeds ventilation. There is an absence of perfusion and ventilation. Ventilation exceeds perfusion. Ventilation matches perfusion.

A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.

A nurse who works in a critical care setting is caring for an adult female patient who was diagnosed with acute respiratory distress syndrome (ARDS) and promptly placed on positive-end expiratory pressure (PEEP). When planning this patient's care, what nursing diagnosis should be prioritized? Impaired gas exchange Risk for aspiration Acute pain Anxiety

Anxiety and pain are both possible during treatment for ARDS. However, maintenance of the patient's airway with the goal of facilitating gas exchange is an absolute priority. The patient's risk of aspiration is low due to NPO status and the presence of inline suctioning.

Prolonged immobility is implicated in the development of which disorder? Bronchitis and bronchiectasis Sarcoidosis and idiopathic pulmonary fibrosis Atelectasis and pulmonary embolism Pulmonary hypertension and cor pulmonale

Lack of mobility can result in secondary atelectasis (through incomplete lung expansion) and pulmonary embolism (from deep vein thrombosis). This is not the case with the other listed disorders of ventilation and gas exchange.

A client who underwent surgery 12 hours ago has difficulty breathing. The client has petechiae over their chest and complains of acute chest pain. What action should the nurse take first? Initiate oxygen therapy. Administer a heparin bolus and begin an infusion at 500 units/hour. Administer analgesics as ordered. Perform nasopharyngeal suctioning.

The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. 1.The nurse should first initiate oxygen therapy 2. notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

A client is diagnosed with pulmonary embolism. Which symptom would most likely be present? Chest pain and dyspnea Shallow respirations and wheezing Left arm pain and diaphoresis Cough and crackles

The manifestations of pulmonary embolism depend on the size and location of the obstruction. Chest pain, dyspnea, and increased respiratory rate are the most frequent signs and symptoms of pulmonary embolism

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing: mitral valve collapse. thrombophlebitis. pulmonary embolism. upper respiratory infection.

These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.

What are potential complications the RN should monitor for in a PE patient??

cardiogenic shock right ventricular failure