A client receiving heparin therapy for deep venous thrombosis complains of severe chest pain and shortness of breath. The nurse suspects pulmonary embolism and should do which of the following actions first?

Question

1. Increase the rate of heparin infusion
2. Apply oxygen and elevate the head of the bed
3. Reassure the client and notify family members
4. Assess pulse, respirations, and blood pressure

Answer 1

2. Apply oxygen and elevate the head of the bed

Rationale:
Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate of heparin infusion will not provide any information on the client's activated partial thromboplastin time (aPTT) level, nor would it provide any information on the physician's order regarding regulating the infusion according to the aPTT level. Reassuring the client and notifying family members are not the priority, although these measures are designed to decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of the bed to increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure will be performed following the initiation of oxygen therapy and bed elevation.