I am very confused about this question.
Patient is in hospital post-op receiving heparin therapy. The patient suddenly presents with chest pain and SOB and the nurse suspects a pulmonary embolus. What is her first nursing action?
a. elevate head of bed and administer oxygen
b. assess pulse, respiratory rate and blood pressure
other choices, I thought not significant were to give more heparin or call the physician.
I could not figure this out due to my brain contradicting itself. At first I thought definitely elevate the bed and give them O2 because A-B-C and airway is so important, no oxygen means not breathing. Then I started to think wait, does the oxygen need a doctor's order? The answer does not specify how much O2 to give. As a nurse presented with little information, would giving O2 be contraindicated for this pt.?
So then I started to think, it must be assess first! Part of nursing process is to ASSESS first, perhaps to see if vital signs confirm the nurse's suspicion then oxygen comes after. You must have a rationale for doing something and assessing would be priority in order to make a decision on what to do next.
In our book it lists both interventions are indicated but not saying which would be priority in this case.
Can anyone give me some insight and provide a rationale for your thinking? Thanks in advance!