The nurse is assessing a client with a suspected pulmonary embolism. Which diagnostic test is most definitive?

Correct Answer: C

Rationale: The correct answer is C: Computed tomography pulmonary angiography (CTPA). This test is most definitive for diagnosing pulmonary embolism as it provides detailed images of the blood vessels in the lungs, allowing for visualization of any blockages. Step-by-step rationale: 1. CTPA is the gold standard diagnostic test for pulmonary embolism due to its high sensitivity and specificity. 2. It can accurately identify the location and size of the blood clot in the pulmonary arteries. 3. CTPA is non-invasive and can be performed quickly, making it a preferred choice in the acute setting. Summary: A (Chest X-ray) is not sensitive enough to diagnose pulmonary embolism. B (D-dimer test) is a screening tool but not definitive for diagnosis. D (V/Q scan) is an alternative test but CTPA is more accurate and widely used.

Correct Answer: B

Rationale: The correct answer is B. Assessing the client's oxygen saturation and respiratory status is the priority. Drowsiness and confusion may indicate oxygen overdose, so assessing these parameters will help determine if the client is experiencing oxygen toxicity. Increasing the oxygen flow rate (choice A) could worsen the symptoms. Discontinuing oxygen therapy (choice C) without assessment could lead to hypoxia. Notifying the healthcare provider (choice D) can be done after the initial assessment.

Correct Answer: D

Rationale: The correct answer is D because auscultating breath sounds is the next appropriate action after noting absent fremitus. This helps assess for additional signs of respiratory issues. Palpating the anterior chest for barrel chest (choice A) is not necessary at this point. Encouraging the patient to turn, cough, and deep breathe (choice B) is more appropriate for assessing for chest expansion. Reviewing the chest x-ray report for evidence of pneumonia (choice C) is premature without further assessment of breath sounds.

Correct Answer: D

Rationale: The correct answer is D because using an albuterol inhaler for peak flows in the yellow zone indicates that the patient understands how to respond to worsening symptoms. Albuterol is a rescue inhaler used to manage asthma exacerbations, which are typically indicated by peak flows in the yellow zone. Inhaling rapidly through the peak flow meter (A) is not the correct technique and can lead to inaccurate readings. Taking montelukast (B) is a daily controller medication and not indicated for immediate symptom relief. Calling the healthcare provider when in the green zone (C) is unnecessary as the green zone signifies good lung function.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulant medication. This is the priority intervention because anticoagulants help prevent the existing clot from getting larger and reduce the risk of new clots forming. Administering anticoagulant medication promptly is essential to prevent complications like worsening of the pulmonary embolism or development of new clots. B: Positioning the patient flat may worsen the condition by reducing blood flow to the lungs. C: Encouraging ambulation may dislodge the clot and lead to a life-threatening situation. D: Chest physiotherapy may not address the underlying cause of the pulmonary embolism and could potentially dislodge the clot. In summary, administering anticoagulant medication is the priority intervention as it directly addresses the pathophysiology of the condition and reduces the risk of complications.