John, a 12-year-old with a fracture of the femur, has developed chest pain and shortness of breath. The nurse suspects a pulmonary embolism. The priority nursing action is to:
1. Elevate the affected extremity.
2. Administer oxygen.
3. Administer pain medication.
4. Start an IV infusion of heparin.
2
Feedback
1. Elevating may make more clots move and increase the risk for more pulmonary emboli.
2. The child needs oxygen to keep the alveoli open within the lungs to prevent respiratory collapse.
3. Pain medication may decrease the respiratory rate and does not aid in decreasing the shortness of breath.
4. The IV heparin needs to be ordered by the doctor.
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