What is the priority nursing intervention for a patient with a newly diagnosed pulmonary embolism?

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.

Correct Answer: D

Rationale: The correct answer is D because assessing the patient's reported exertional dyspnea directly evaluates the symptom that the patient is experiencing. Improvement in exertional dyspnea indicates that the treatment is effective in managing the patient's condition. It is essential to focus on the patient's subjective experience to determine treatment effectiveness. Choices A, B, and C are incorrect because: A: Heart rate below 100 beats per minute may or may not be relevant to assessing exertional dyspnea improvement. It does not directly evaluate the patient's reported symptom. B: Improved lung fields on a chest x-ray may suggest some improvement but do not directly correlate with the patient's symptom of exertional dyspnea. C: Stable blood pressure is important but does not directly assess the patient's reported symptom of exertional dyspnea.

Correct Answer: B

Rationale: The correct answer is B: Paradoxical chest wall movement. This finding is most concerning because it indicates a flail chest, a serious condition where a segment of the chest wall moves in the opposite direction of the rest of the chest during breathing, leading to respiratory compromise and potential lung injury. This requires immediate medical intervention. A: Mild chest wall bruising is less concerning as it may be a common finding in chest trauma without indicating severe underlying issues. C: A respiratory rate of 20 breaths per minute falls within the normal range and may not necessarily indicate a critical condition. D: Subcutaneous emphysema near the injury site can be concerning but is typically not as immediately critical as paradoxical chest wall movement in terms of respiratory compromise.

Correct Answer: C

Rationale: The correct answer is C. This statement is incorrect because stopping tuberculosis medications prematurely can lead to treatment failure and the development of drug-resistant strains. Patients must complete the full course of treatment to ensure the infection is completely eradicated. Wearing a mask to prevent spreading the infection, taking medication for at least 6 months as prescribed, and scheduling regular follow-up appointments are all essential steps in managing tuberculosis effectively.

Correct Answer: B

Rationale: The correct answer is B: Identify and avoid environmental triggers. This is the most important point because it addresses the root cause of allergic rhinitis, which is exposure to allergens. By identifying and avoiding triggers such as pollen, dust mites, and pet dander, the patient can effectively manage their symptoms. Using oral antihistamines preemptively (choice A) may provide some relief, but does not address the underlying cause. Washing hands frequently (choice C) is important for preventing infections but not directly related to managing allergic rhinitis. Limiting corticosteroid nasal sprays (choice D) is incorrect as they are commonly used and effective in managing allergic rhinitis symptoms without significant systemic effects when used as directed.