Medical Surgical Pulmonary embolism #1
The nurse caring for a client who had a right wedge resection of the lung recognizes an early sign of pulmonary emboli. Which assessment finding is an early sign of pulmonary embolism?
- Cyanosis localized to the upper extremities.
This answer is not correct because cyanosis to the upper extremities is not an early sign of pulmonary embolus. Cyanosis is a late sign of prolonged hypoxemia.
- Increased wheezing bilaterally.
This answer is not correct because wheezing is not associated with pulmonary embolus. Wheezing is an indicator of bronchospasm and bronchoconstriction as seen in clients with asthma and COPD.
- Increase in respirations by 10 breaths per minute over two hours.
This answer is not correct because with a pulmonary embolus, the client’s respiratory rate would increase abruptly as opposed to slowly, over a two-hour period. Hyperventilation would occur nearly immediately as a result of hypoxemia and air hunger.
- Sudden onset of apprehension, anxiety, and dyspnea.
This answer is correct because pulmonary embolism symptoms may be sudden, and the client may feel paniced and apprehensive with abrupt dyspnea, and have chest pain. Respiratory rate increase also may occur abruptly.
The focus of this question is determining an early expected finding in a client with a pulmonary embolus. It is essential to learn the expected manifestations of pulmonary embolus in order to answer this question correctly. A client with a pulmonary embolus will be anxious, apprehensive, restless, and dyspneic as a result of sudden, severe hypoxemia.
Clinical manifestations of a pulmonary embolus result from hypoxia and air hunger. One of the earliest indicators of hypoxia is a change in the client’s mental status. Sudden apprehension, anxiety, restlessness, agitation, and confusion are early manifestations of hypoxia caused by a pulmonary embolus. Hypoxemia causes dyspnea and air hunger.
Test Taking Tip
“Early” is a keyword to take into account when answering this question. Cyanosis is a very late sign of hypoxemia which would automatically eliminate that as a possible answer choice.