A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52
mm Hg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the client’s lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for
speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE.
What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found.
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk
factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development
of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client’s oxygen saturation has not
significantly improved. What response by the nurse is best?
a. “Breathing so rapidly interferes with oxygenation.”
b. “Maybe the client has respiratory distress syndrome.”
c. “The blood clot interferes with perfusion in the lungs.”
d. “The client needs immediate intubation and mechanical ventilation.”

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