The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately?
a. Respiratory rate of 28 breaths/min
b. Urinary output of 10 mL/hr
c. Heart rate of 100 beats/min
d. Dry cough
B
Urinary output is very low; this could indicate that the client has decreased cardiac output. The nurse will need to intervene and notify the health care provider. A respiratory rate that is slightly elevated is expected in this condition. Likewise, a heart rate that is a little higher is expected in this situation. A dry cough is also commonly found with pulmonary embolus.
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