what is the priority intervention for a patient with suspected pulmonary embolism

ATI RN

ATI RN Exit Exam

1. What is the priority intervention for a patient with suspected pulmonary embolism?

A. Administer oxygen
B. Administer anticoagulants
C. Administer bronchodilators
D. Reposition the patient

Correct answer: A

Rationale: Administering oxygen is the priority intervention for a patient with suspected pulmonary embolism. Maintaining adequate oxygenation is crucial in these patients to prevent hypoxemia and support oxygen delivery to tissues. Administering anticoagulants may be necessary but is not the initial priority. Administering bronchodilators is not indicated for pulmonary embolism. Repositioning the patient does not address the immediate need for oxygenation.

2. Which electrolyte imbalance is commonly associated with furosemide?

A. Hypokalemia
B. Hyponatremia
C. Hyperkalemia
D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, commonly causes the loss of potassium in the urine, leading to hypokalemia. This electrolyte imbalance can result in various complications such as cardiac arrhythmias and muscle weakness. Choice B, Hyponatremia, is not typically associated with furosemide use. Choice C, Hyperkalemia, is the opposite of the expected electrolyte imbalance caused by furosemide. Choice D, Hypercalcemia, is not a common side effect of furosemide.

3. A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle changes to manage the condition. Which of the following instructions should the nurse include?

A. Avoid eating small, frequent meals.
B. Sleep with the head of your bed elevated.
C. Lie down after eating.
D. Avoid drinking fluids with meals.

Correct answer: B

Rationale: The correct answer is B: 'Sleep with the head of your bed elevated.' Elevating the head of the bed helps reduce acid reflux by keeping the head higher than the stomach, preventing stomach acid from flowing back into the esophagus. Choices A, C, and D are incorrect. Avoiding eating small, frequent meals, lying down after eating, and drinking fluids with meals can exacerbate GERD symptoms by increasing stomach acid production and promoting acid reflux.

4. Which lab value should be monitored in patients receiving heparin therapy?

A. Monitor aPTT
B. Monitor INR
C. Monitor platelet count
D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT in patients receiving heparin therapy. Activated Partial Thromboplastin Time (aPTT) is crucial to assess the therapeutic effectiveness of heparin and to prevent bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy, not heparin. Platelet count (Choice C) monitoring is essential for detecting heparin-induced thrombocytopenia rather than assessing heparin therapy itself. Monitoring sodium levels (Choice D) is not directly related to heparin therapy monitoring.

5. A nurse is caring for a client who is 12 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A. Serosanguineous drainage on the surgical dressing.
B. Respiratory rate of 16/min.
C. Heart rate of 90/min.
D. WBC count of 15,000/mm3.

Correct answer: D

Rationale: A WBC count of 15,000/mm3 is elevated, which may indicate infection, a common concern postoperatively. An elevated WBC count suggests the body is fighting an infection, and prompt reporting to the provider is essential for further evaluation and treatment. Serosanguineous drainage on the surgical dressing is expected in the immediate postoperative period, respiratory rate of 16/min is within the normal range, and a heart rate of 90/min is also within an acceptable range postoperatively. Therefore, these findings do not raise immediate concerns that necessitate reporting to the provider.