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?
Explanation & Rationale
A. Blood pressure 140/90 mm Hg: This blood pressure reading is elevated but does not specifically suggest a pulmonary embolism (PE). It could be due to other factors such as anxiety or pain, and it is not a primary indicator of PE. B. Respiratory rate 12/min: A respiratory rate of 12/min is within the normal range (12-20 breaths per minute). A PE typically causes an increased respiratory rate as the body attempts to compensate for impaired oxygenation: normal respiratory rate does not suggest PE. C. Temperature 40° C (104° F): A fever of 40° C (104° F) is significantly elevated and suggests an infection or inflammation. While a PE can cause mild fever, a temperature of 40° C is more commonly associated with infection rather than a pulmonary embolism. D. Heart rate 120/min: A heart rate of 120/min is indicative of tachycardia, which is a common response to a pulmonary embolism. The body tries to compensate for reduced oxygenation by increasing heart rate. Tachycardia, along with other symptoms such as shortness of breath and chest pain, is a key indicator of PE.