A client is admitted with a suspected pulmonary embolism (PE). What is the nurse's priority intervention?

Correct Answer: D

Rationale: In the context of a client with a suspected pulmonary embolism (PE), the nurse's priority intervention should be to prepare the client for a CT scan (Option D). A CT scan is the gold standard diagnostic test for confirming the presence of a pulmonary embolism. Timely diagnosis is crucial in initiating appropriate treatment and preventing potential complications such as cardiopulmonary collapse. Administering anticoagulant therapy (Option A) is a common treatment for PE, but it should not be initiated without a confirmed diagnosis. Elevating the head of the bed (Option B) is important for optimizing respiratory function in patients with respiratory distress, but it is not the priority over confirming the diagnosis. Checking the client's oxygen saturation (Option C) is important for assessing respiratory status, but it does not address the immediate need for diagnostic confirmation in a suspected PE case. In an educational context, this question highlights the importance of prioritizing interventions based on the urgency of the situation. It reinforces the significance of diagnostic tests in guiding appropriate treatment decisions and emphasizes the critical role of nurses in advocating for timely and accurate diagnostic procedures to ensure optimal patient outcomes.

Correct Answer: C

Rationale: In the context of a client with a colostomy being discharged, the most important teaching for the nurse to provide is to empty the ostomy pouch when it is one-third full, which is option C. This is crucial for maintaining skin integrity, preventing leakage, and ensuring proper functioning of the colostomy. By emptying the pouch at the appropriate time, the client can avoid potential complications such as skin irritation, leakage, and discomfort. Option A, changing the ostomy bag daily, is incorrect as it is not necessary to change the entire bag daily unless there is a specific issue. This practice can be wasteful, costly, and may increase the risk of damaging the peristomal skin. Option B, avoiding gas-producing foods like broccoli, is important for some individuals with colostomies to minimize gas and odor, but it is not the most critical teaching point for discharge. It is more of a dietary recommendation rather than a fundamental aspect of colostomy care. Option D, using a skin barrier to protect the surrounding skin, is essential for preventing skin breakdown and irritation; however, it is not as critical as ensuring timely emptying of the ostomy pouch. While using a skin barrier is important, it is a preventive measure rather than a direct action that impacts the functionality of the colostomy. In an educational context, understanding the proper care of a colostomy is vital for nurses working with clients who have undergone ostomy surgery. By prioritizing teachings like timely pouch emptying, nurses can help clients maintain independence, quality of life, and prevent complications related to their colostomy.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Bradycardia of 50 beats per minute. Digoxin is a medication commonly prescribed for heart failure because it helps the heart beat stronger and pump more blood. However, one of the potential side effects of digoxin toxicity is bradycardia, a slow heart rate. A bradycardic heart rate of 50 beats per minute in a client taking digoxin can be indicative of toxicity and can lead to serious complications like life-threatening arrhythmias. Option B) Heart rate of 110 beats per minute is incorrect because it is within the normal range and not a concerning finding in a client with heart failure on digoxin. Option C) Respiratory rate of 16 breaths per minute is also within normal limits and does not directly relate to digoxin toxicity. Option D) Blood pressure of 130/80 mmHg is also within normal range and not a priority finding in this context. Educationally, this question highlights the importance of recognizing signs of digoxin toxicity in clients with heart failure. Nurses must be vigilant in monitoring heart rates in patients on digoxin to prevent adverse effects and provide timely interventions. Understanding the side effects and implications of medications used in heart failure management is crucial for safe and effective nursing practice.

Correct Answer: B

Rationale: In a client with diabetic ketoacidosis (DKA), the nurse should closely monitor the blood glucose level, making option B the correct answer. DKA is a serious complication of diabetes characterized by high blood sugar levels, dehydration, and ketone formation. Monitoring blood glucose levels is crucial in managing DKA as it indicates the effectiveness of treatment and helps prevent complications such as cerebral edema. Option A, a white blood cell count of 15,000, may indicate an infection but is not the most critical parameter to monitor in DKA. Option C, a sodium level of 145 mEq/L, is within normal range and not directly related to DKA management. Option D, a serum creatinine level of 1.0 mg/dL, assesses kidney function and may be important for overall health assessment but is not as immediately relevant as monitoring blood glucose levels in DKA. Educationally, understanding the importance of monitoring specific laboratory values in DKA highlights the critical thinking skills required in nursing practice. It reinforces the need for prioritization of care based on the client's condition and the significance of timely interventions to prevent complications and promote positive outcomes for the client.

Correct Answer: A

Rationale: The correct answer is A) Monitor the client's respiratory rate. When a client is receiving morphine, a potent opioid analgesic, there is a risk of respiratory depression as one of the side effects. Respiratory depression can be life-threatening and requires immediate intervention. Therefore, assessing the client's respiratory rate is crucial to detect any signs of respiratory distress early on. Option B) Monitor the client's level of consciousness is important, but respiratory rate takes priority as it directly reflects respiratory function, which is essential for life. Option C) Assess the client's level of pain is important for providing holistic care, but in this scenario, the priority is to ensure the client's physiological safety. Option D) Monitor the client's blood pressure is not the priority in this situation. While it is important to monitor blood pressure, it is not the most critical assessment when a client is receiving morphine and at risk for respiratory depression. In an educational context, this question highlights the importance of prioritizing assessments based on the potential risks associated with specific medications. It emphasizes the need for nurses to be vigilant in monitoring clients for adverse effects and taking prompt action to ensure client safety.