A client who is 2 days postoperative from a bowel resection tells her nurse that she is having a hard time "catching her breath," feels nauseated, and has chest pains when she inhales. The nurse suspects that she is having a pulmonary embolism
What intervention should the nurse perform before notifying the physician? A. Increase the IV flow rate.
B. Apply oxygen by mask or nasal cannula at 5 L/min.
C. Assess the chest and axillary area for the presence of petechiae.
D. Place the client in shock position, with her head and neck flat and her legs ele-vated.
B
If this client is having a pulmonary embolism, she is hypoxic and at risk for other complications and tissue damage. Applying oxygen in this situation can be helpful and is unlikely to cause any problems. Increasing the IV flow rate and assessing for petechiae will not prevent problems. Both of these actions can be performed after the physician is notified. Placing the client in shock position will not improve the hypoxia and may increase the extent of the pulmonary vascular block.
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