NCLEX-PN® ExaminationPhysiological AdaptationMedium
A client presents to the emergency department with sudden-onset shortness of breath, pleuritic chest pain, and a feeling of impending doom. The client denies any recent trauma but reports a long flight yesterday. On assessment, the nurse notes tachycardia, tachypnea, and oxygen saturation of 88% on room air. Which of the following initial nursing interventions is the most appropriate?
- APrepare the client for immediate insertion of a chest tube.
- BApply oxygen via nasal cannula and elevate the head of the bed.
- CAdminister a prescribed oral analgesic for chest pain.
- DInitiate continuous cardiac monitoring and obtain a 12-lead ECG.
Show answer & explanationAnswer & explanation
Correct answer: B. Apply oxygen via nasal cannula and elevate the head of the bed.
The client's symptoms are highly suggestive of a pulmonary embolism (PE). The priority in PE is to improve oxygenation and reduce respiratory distress. Applying oxygen and elevating the head of the bed directly addresses these immediate needs.
Why the other options are wrong
- A. A chest tube is indicated for pneumothorax or hemothorax, not typically for pulmonary embolism, unless there are other complications not indicated here.
- C. Analgesics may be needed, but improving oxygenation is the immediate priority over pain management for a life-threatening respiratory issue.
- D. While cardiac monitoring and ECG are important for assessing cardiac strain, the immediate life-threatening issue is hypoxemia, which needs to be addressed first.
Pulmonary Embolism (PE) Initial Management
Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs. Initial management focuses on improving oxygenation and stabilizing the client.
- Symptoms often include sudden dyspnea, pleuritic chest pain, and hypoxemia.
- Risk factors include prolonged immobility, surgery, and certain medical conditions.
- Immediate interventions prioritize oxygenation and client comfort.
Memory trick: OXYGEN First for PE, then Doctor's orders decree!