NCLEX Question of the Day
Physiological Adaptation QID 1220
The nurse is caring for a client with a pulmonary embolism. Which intervention should the nurse implement first?
Explanation
**Rationale:** A pulmonary embolism (PE) obstructs pulmonary blood flow, impairing oxygenation. The first priority is to address hypoxia by **administering oxygen via nasal cannula** to improve oxygen saturation and stabilize the client, aligning with the ABCs (airway, breathing, circulation) of the nursing process. **Initiating an IV heparin infusion** is critical to prevent clot extension but is not the immediate action, as oxygenation takes precedence. **Elevating the head of the bed to 90 degrees** may improve breathing but does not directly address hypoxia as effectively as oxygen therapy. **Obtaining a 12-lead ECG** is diagnostic and may show right heart strain, but it is not the first intervention. Patient safety hinges on restoring oxygenation promptly.
GoodNurse AI
Sign up to access GoodNurse AI, a one-of-a-kind AI tutor who assists you in understanding practice questions better. You can either type in your own question or choose from a list of pre-written questions. GoodNurse AI offers clear explanations and guidance to enhance your learning.