Pulmonary embolism

Question

An adult client is recovering on a surgical unit after an operation.

Step 1

Which findings in the note require immediate attention? Select all that apply.

1. ASudden difficulty breathing✓ Correct

   Sudden breathing difficulty calls for emergency assistance and can occur with pulmonary embolism.

2. BCoughing up blood✓ Correct

   Coughing up blood can be a sign of pulmonary embolism.

3. CChest pain✓ Correct

   Chest pain can occur with pulmonary embolism.

4. DThe client is an adult✗ Incorrect

   Adult age alone is not an acute symptom of pulmonary embolism.

5. EThe client is on a surgical unit✗ Incorrect

   A surgical unit is a location, not an acute symptom of pulmonary embolism.

Rationale. Abrupt breathing difficulty, pain, and blood in the sputum can occur with an embolism. The client’s age group and location alone are not acute symptoms.

Step 2

What complication could explain this cluster of findings?

1. AA pulmonary embolism✓ Correct

   Pulmonary embolism can cause breathlessness, pain, coughing up blood, and restlessness.

2. BA separated surgical incision✗ Incorrect

   A separated incision describes a wound complication; it does not account for the respiratory symptom cluster.

3. CUrinary retention✗ Incorrect

   Urinary retention concerns bladder emptying; it does not account for the respiratory symptom cluster.

4. DA urinary tract infection✗ Incorrect

   A urinary tract infection concerns the urinary tract; it does not account for the respiratory symptom cluster.

Rationale. A clot obstructing pulmonary circulation can present with breathing difficulty and blood-streaked sputum. The other choices do not explain this respiratory cluster.

Step 3

Which issue requires the most urgent response?

1. AThe sudden difficulty breathing✓ Correct

   Sudden breathlessness calls for emergency assistance.

2. BThe timing of routine paperwork✗ Incorrect

   Routine paperwork does not address sudden breathlessness, which needs emergency assistance.

3. CThe client’s meal selection✗ Incorrect

   Meal selection does not address sudden breathlessness, which needs emergency assistance.

4. DThe next scheduled linen change✗ Incorrect

   A linen change does not address sudden breathlessness, which needs emergency assistance.

Rationale. Sudden respiratory distress requires emergency assistance. Routine tasks should wait while the nurse responds.

Step 4

Which intervention should be included in the immediate response?

1. AProvide oxygen✓ Correct

   Oxygen helps oxygenate blood that continues past an embolism.

2. BDelay help until the next scheduled round✗ Incorrect

   Sudden breathlessness calls for immediate emergency assistance, not a delayed response.

3. COffer a meal to reduce restlessness✗ Incorrect

   A meal does not provide oxygen or emergency assistance for sudden breathlessness.

4. DAsk the client to exercise in the hallway✗ Incorrect

   Hallway exercise does not provide oxygen or emergency assistance for sudden breathlessness.

Rationale. Oxygen supports oxygenation while emergency help is summoned. Routine activities do not address the acute respiratory problem.

Step 5

What should the nurse do for the abrupt respiratory change?

1. ARequest emergency assistance immediately✓ Correct

   Sudden breathlessness calls for emergency assistance immediately.

2. BWait to see whether the next meal helps✗ Incorrect

   Waiting for a meal does not provide immediate emergency assistance.

3. CSchedule a routine discussion for tomorrow✗ Incorrect

   A discussion tomorrow does not provide immediate emergency assistance.

4. DLeave the client to complete paperwork✗ Incorrect

   Completing paperwork does not provide immediate emergency assistance.

Rationale. The sudden onset calls for immediate help. Waiting postpones treatment of a potentially dangerous complication.

Step 6

Which observation would best indicate improvement in the presenting respiratory problem?

1. AThe client reports breathing is easier✓ Correct

   Easier breathing indicates that breathlessness has lessened.

2. BThe client reports increasing breathlessness✗ Incorrect

   Increasing breathlessness indicates worsening rather than improvement in breathing.

3. CThe client coughs up more blood✗ Incorrect

   More blood in the sputum is worsening of a possible pulmonary embolism symptom, not improved breathing.

4. DThe client becomes more restless✗ Incorrect

   Increasing restlessness is worsening of a possible pulmonary embolism symptom, not improved breathing.

Rationale. Less breathlessness is a favorable change in the presenting symptom. Increasing distress, bleeding, or restlessness calls for further urgent attention.

Rationale

A clot obstructing pulmonary circulation can present with breathing difficulty and blood-streaked sputum. The other choices do not explain this respiratory cluster. Oxygen supports oxygenation while emergency help is summoned. Routine activities do not address the acute respiratory problem.