A client receiving heparin therapy for deep venous thrombosis (DVT) complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, which is the priority action by the nurse?
A) Assess pulse, respirations, and blood pressure.
B) Apply oxygen and elevate the head of the bed.
C) Reassure the client and notify family members.
D) Increase the rate of heparin infusion.
Answer: B
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 cannot be done by the nurse without an order from a healthcare provider. Reassuring the client and notifying family members are not priorities, although these measures can 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.
You might also like to view...
The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which of the following should the nurse expect to be used?
a. Ultrasonography b. An ophthalmoscope c. A slit-lamp microscope d. A tonometer
A patient on penicillamine therapy should:
1. have frequent blood and urine checks to monitor for adverse reactions. 2. be assessed for changes in vision. 3. be assessed for trouble breathing. 4. be assessed for blood in the stool.
Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated?
a. The client has dry, scaly skin on bilateral upper and lower extremities. b. The client states that he gets up three or more times during the night to urinate. c. The client states that he feels lightheaded when he gets out of bed or stands up. d. The nurse observes tenting on the back of the hand when testing skin turgor.
Which medications increase the outflow of aqueous humor? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected
1. Miotics 2. Sympathomimetics 3. Prostaglandins 4. Beta blockers 5. Prostamides