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1. Question
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?
Correct
Answer: Option 3 is the correct answer.
Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis. Test-Taking Strategy: Note the strategic word, most. Because pulmonary embolism does not result from an infectious process or an allergic reaction, eliminate options 1 and 2 first. To select between the correct option and option 4, look at them closely. Option 4 states dyspnea when deep breaths are taken. Although dyspnea commonly occurs with pulmonary embolism, dyspnea is not associated only with deep breathing. Therefore, eliminate option 4.
Incorrect
Answer: Option 3 is the correct answer.
Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis. Test-Taking Strategy: Note the strategic word, most. Because pulmonary embolism does not result from an infectious process or an allergic reaction, eliminate options 1 and 2 first. To select between the correct option and option 4, look at them closely. Option 4 states dyspnea when deep breaths are taken. Although dyspnea commonly occurs with pulmonary embolism, dyspnea is not associated only with deep breathing. Therefore, eliminate option 4.
Pulmonary embolism
Pulmonary embolism Occurs when a thrombus forms (most commonly in a deep vein), detaches, travels to the right side of the heart, and then lodges in a branch of the pulmonary artery.
Pulmonary embolism is caused by the movement of foreign particles (blood clot, fat, or air) into the pulmonary circulation.
Nursing Assessment
Restlessness and apprehension
Sudden onset of dyspnea and chest pain
Cough, hemoptysis, hypoxemia, or crackles
Nursing Interventions
Notify the HCP immediately if signs of emboli
are present.
Administer oxygen and other prescriptions; intravenous
(IV) anticoagulant therapymay be prescribed.
