Week 2 PE Flashcards
The nurse has completed discharged planning with her client who was treated for a pulmonary embolism and will be on warfarin for a few more months. Which
statement by the nurse indicates teaching has been effective?
“It is okay to shave every day with a regular razor.”
“I will be okay going back to my job that requires me to sit for long periods of time.”
“I will contact my health care provider (HCP) if I have trouble breathing or chest pain.”
“I will continue my regular diet of lean meats, potatoes, and dark leafy greens.”
“I will contact my health care provider (HCP) if I have trouble breathing or chest pain.”
This answer is correct because anyone having trouble breathing and chest pain should call 9-1-1 or go to their nearest emergency department. The sooner the client is treated with a thrombolytic, the better potential for a positive outcome.
Which client is at the highest risk for a pulmonary embolism?
A 67-year old client with exacerbation of congestive heart failure.
A 30-year old pregnant client at 30-weeks gestation.
A 59-year-old client status post-femur fracture.
A 45-year-old on hormone replacement therapy.
A 59-year-old client status post-femur fracture.
This answer is correct because this client has three risk factors for pulmonary embolism. The client is at an advanced age, has a fracture of a long bone, and is immobile. Fracture of a long bone, such as the femur can produce a fat emboli. That coupled with the fact that the client is immobile due to the leg fracture, puts the client at higher risk for pulmonary embolism.
A client is receiving continuous IV heparin for the diagnosis of pulmonary embolism (PE). Which observation by the nurse requires the IV to be stopped and a STAT aPTT level performed?
Chills with pain and numbness in arms and legs.
Coughing productive of blood-tinged sputum.
Client complains of a headache and is sweaty.
Pinpoint-sized red and purple spots on the client’s arms and legs.
Pinpoint-sized red and purple spots on the client’s arms and legs.
This answer is correct because this is called petechiae and is a hallmark sign of bleeding. The nurse will obtain aPTT so the health care provider (HCP) can reevaluate the dose of heparin. In some cases, the client may be changed over to oral anticoagulation with consistent monitoring of INR, PT, and aPTT lab studies.
The nurse is preparing a room for a client coming to her floor from the ER with the diagnosis of pulmonary embolism. Which actions by the nurse are indicated? Select all that apply.
Raise the head of the bed 45 degrees.
Have incentive spirometry available.
Place intubation equipment at the bedside.
Place an IV pump in the room.
Station a bedside commode.
Have incentive spirometry available.
Place intubation equipment at the bedside.
Place an IV pump in the room.
This answer is correct because a pulmonary embolism causes the lungs to contract and lose volume. Coughing and deep breathing helps inflate the lungs. The incentive spirometer is a great tool to assist in lung rehabilitation. The incentive spirometer requires a prescription.
This answer is correct because for clients who are at risk of severe hypoxemia, intubation supplies should always be at the bedside. If the PE causes right ventricular failure, arterial hypoxemia ensues. Airway and breathing are always priorities.
This answer is correct because a pulmonary embolism will be treated with intravenous anticoagulation. By having the IV pump in the room, the nurse is anticipating the need to start anticoagulation therapy. If the client experiences a massive thromboembolism, the use of thrombolytic therapy will also be administered intravenously.
The nurse caring for a client who had a right wedge resection of the lung recognizes an early sign of pulmonary emboli. Which assessment finding is an early sign of pulmonary embolism?
Cyanosis localized to the upper extremities.
Increased wheezing bilaterally.
Increase in respirations by 10 breaths per minute over two hours.
Sudden onset of apprehension, anxiety, and dyspnea.
Sudden onset of apprehension, anxiety, and dyspnea.
This answer is correct because pulmonary embolism symptoms may be sudden, and the client may feel paniced and apprehensive with abrupt dyspnea, and have chest pain. Respiratory rate increase also may occur abruptly.
