The nurse receives change-of-shift report on the following four ...

[Shelles]

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
 
  a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
  b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
  c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
  d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)

Question 2

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute.
 
  Which action should the nurse take first?
  a. Administer anticoagulant drug therapy.
  b. Notify the patient's health care provider.
  c. Prepare patient for a spiral computed tomography (CT).
  d. Elevate the head of the bed to a semi-Fowler's position.

[sierramartinez]

Answer to Question 1

ANS: B
Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

Answer to Question 2

ANS: D
The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.