Problem with prioritizing

beth66335, BSN, RN · Jun 15, 2009

I am having the hardest time with prioritizing and I am in my 5th semester. Will I ever be able to answer questions on the NCLEX accurately? I had an OB exam today, but this question can also be applied to any med-surg patient. The patient had an embolism, after applying Oxygen, what is my next action:
1. Call for assistance
2. Insert a Foley
3. Prepare to Intubate
Ok...to be honest, I over read in the book. I know with a PE, patient can develop pulm. edema as a consequence. But would I start to monitor output so early?
Thanks in advance for any assistance
-Niesy

Keep in mind your ABC's. The patients airway is compromised and nurses don't intubated people, so calling for help is your next step. ABC's and scope of practice.

cursedandblessed · Jun 15, 2009

that's where i find a lot of my fellow students have problems with the questions: they forget that silly little thing you learn in cpr:

airway

breathing

circulation

(being facetious there)

patient having sob: raise the head of the bed, administer o2

with the choices you were given you can rule out a foley right away: has nothing to do with the patient's problem o2 getting in and perfusing the tissues.

intubation: has to do with oxygen, but really that's a doc's call and i can't think of any situation except perhaps field medicine in the military that a nurse could/would make a decision like that or do the procedure.

call for help: well patient has a pulmonary embolis, i think i'd want some help. most logical decision to make.

NiesyLuv0o · Jun 15, 2009

I know...it was one of those silly answers that will bug me for like 3 days. Iknew it was to call for help and that's why it is such an annoyance to me know.

Most of the times, the questions will not apply ABC rules....so then it is just critical thinking at this point.

Thanks

Daytonite, BSN, RN · Jun 16, 2009

i had an ob exam today. the patient had an embolism, after applying oxygen, what is my next action:

call for assistance
insert a foley
prepare to intubate

after applying oxygen the patient should be repositioned so she can breathe easier, but the stem of the question doesn't indicate anything about the patient's position and neither does the reasoning for

call for assistance

. the question is asking for the nurse's next

action

. i wouldn't consider calling for anyone as an action especially when it doesn't say why. if i'm putting oxygen on someone i know they are having trouble breathing. i'm thinking about the worst thing that could happen and that is a respiratory arrest and that means intubation. i would call for assistance if the patient coded.

i double checked this in several places. page 738 of

saunders comprehensive review for the nclex-

rn

examination

, 3rd edition, by linda anne silvestri on the interventions for a pulmonary embolism lists the following:

administer oxygen as prescribed. (given in the stem on the question.)
position client in high fowler's position.
monitor lung sounds.
maintain bed rest and active and passive range of motion exercises as prescribed.
encourage use of incentive spirometry as prescribed.
monitor pulse oximetry.
prepare for intubation and mechanical ventilation for severe hypoxemia.
administer anticoagulation therapy intravenously with heparin sodium (bolus), followed by continuous infusion during acute phase.
administer warfarin (coumadin) orally, as prescribed, when heparin infusion is discontinued.
monitor prothrombin time and partial thromboplastin time closely.
prepare the client for embolectomy, vein ligation, or insertion of an umbrella filter, as prescribed.

page 336-7 of

foundations of maternal-newborn nursing

, 4th edition, clinical companion, by sharon smith murray and emily slone mckinney says this about postpartum pulmonary embolism:

"pulmonary embolism is a rare but potentially life-threatening complication of dvt. it occurs when fragments of a blood clot or amniotic fluid and its debris are carried to the pulmonary artery or one of its branches. this occludes the vessel and obstructs the flow of blood into the lungs. . .treatment is aimed at dissolving the clot and maintaining pulmonary circulation.

give oxygen (8-10 l/min) to decrease hypoxia.
administer analgesics to relieve pain.
elevate the head of the bed slightly to reduce dyspnea.
initiate pulse oxymetry to evaluate oxygen saturation.
administer intravenous heparin or thrombolytic drugs, such as streptokinase or urokinase. embolectomy may be performed.
obtain critical care nursing for support of ventilation and cardiovascular status.

nursing considerations [include]

be aware of the signs and symptoms of pulmonary embolism and be vigilant in assessments of women with thrombosis.
report any sign of embolism to the healthcare provider.
when signs of embolism are present, obtain assistance, position the woman to reduce dyspnea, and begin oxygen administration.
the nurse should remain with the woman and provide information and support to a family that usually becomes increasingly fearful."

the signs and symptoms of pulmonary embolism are:

restlessness
cough
blood-tinged sputum
sudden, sharp chest pain
dyspnea for no apparent reason with angina or pleuritic pain
hypotension
wheezing, rales, crackles
shallow respirations
weak rapid pulse
tachypnea
with a large embolus:
cyanosis, syncope, distended neck veins

if this is the exact way the question was written i would petition for the question to be thrown out since answer choice #1 is vague if it is the correct answer.

NiesyLuv0o · Jun 16, 2009

Thank You DayToNite. This is exactly how it was written. It bothered me soooo mcuh, I remember it clearly. I was thinking to intubate, but I did not select it because I thought it is not necessary to intubate at this moment. I did put insert the foley, which is a silly choice bcause that is not an emergency intervention.

Daytonite, BSN, RN · Jun 16, 2009

i worked on a stepdown down unit for a long time and was a supervisor. my first inclination would have been to get the intubation tray ready. but, because this is a student forum i double-check my answers, so i looked in a couple of my books over here and copied what was in two of them. they were word for word out of the books, so if you want to use them, be my guest. the answer choice call for assistance was probably meant to be in reference to repositioning the patient so she could breathe easier, but it doesn't say that which makes it a poor answer choice. that is why i would fight to have the question dumped telling the instructor you would have chose it if it said call for assistance to help reposition the patient into high fowler's position and get yourself a couple of points back.