A nurse is caring for a client who has a deep vein thrombosis. Which of the following findings should indicate to the nurse that the client could be experiencing a pulmonary embolism?

Nursing care for a client with deep vein thrombosis (DVT) requires vigilant monitoring for complications, especially pulmonary embolism (PE), which occurs when a thrombus dislodges and travels to the pulmonary circulation. Deep vein thrombosis can progress to Pulmonary embolism, a life-threatening condition that impairs gas exchange and cardiac function. Early recognition of clinical signs such as sudden tachycardia, dyspnea, and hypoxemia is essential for prompt intervention and prevention of respiratory collapse. Rationale: A. A respiratory rate of 12/min is within the normal adult range and does not indicate pulmonary embolism. In PE, the expected respiratory response is tachypnea due to hypoxia and impaired oxygen exchange. A normal or low respiratory rate does not support the presence of acute pulmonary compromise. B. A temperature of 40°C (104°F) suggests severe infection or systemic inflammatory response rather than pulmonary embolism. Although mild low-grade fever can sometimes occur with PE due to inflammatory processes, a markedly elevated temperature is not characteristic and should prompt evaluation for infectious causes such as sepsis or pneumonia. C. A heart rate of 120/min is an important indicator of possible pulmonary embolism because tachycardia is a compensatory response to decreased oxygenation and increased pulmonary vascular resistance. When a clot obstructs pulmonary blood flow, the heart increases rate to maintain cardiac output. Sudden unexplained tachycardia in a client with DVT is a red flag requiring immediate evaluation. D. A blood pressure of 140/90 mm Hg is not typically associated with pulmonary embolism. In fact, PE more commonly leads to hypotension due to right ventricular strain and decreased left ventricular filling in severe cases. Elevated blood pressure does not support the presence of acute embolic obstruction.