A triage nurse is assessing a client in an emergency department. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Rationale for Correct Choices • Pulmonary embolism: The client presents with sudden, severe chest pain rated 10/10, tachycardia (122/min), tachypnea (25/min), hypotension (77/45 mm Hg), and hypoxemia (SpO₂ 85%). These findings are consistent with a massive pulmonary embolism causing impaired pulmonary circulation and right-sided cardiac strain. Anxiety and “feels like something bad is going to happen” are also common subjective findings. • Elevate head of the bed: This positioning improves lung expansion, decreases work of breathing, and enhances oxygenation in a client with impaired pulmonary perfusion. • Administer anticoagulant: Anticoagulants (e.g., heparin) are first-line treatment to prevent further clot formation and reduce progression of the embolism. • Respiratory effort: Monitoring work of breathing helps evaluate worsening hypoxia and effectiveness of oxygenation/ventilation support. • aPTT (pTT): If heparin is used, aPTT is monitored to ensure therapeutic anticoagulation and prevent bleeding complications Rationale for Incorrect Choices • Tension pneumothorax: Would present with absent or markedly diminished breath sounds on one side, tracheal deviation, and unilateral chest findings—none are present (lung sounds are vesicular bilaterally and trachea is midline). • Gastric reflux disease: Would cause burning epigastric pain, often related to meals, not severe hypoxia, hypotension, or tachycardia. • Palpitations: Would not explain severe hypotension, hypoxemia, or respiratory distress. • Teach client to avoid fried and spicy foods: Appropriate for GERD, not acute cardiopulmonary collapse. • Encourage client to consume less caffeine: May reduce palpitations or anxiety symptoms but does not address life-threatening hypoxia and hypotension. • Assist with chest tube insertion: Indicated for tension pneumothorax, not pulmonary embolism. • Chest tube drainage: Not applicable because no chest tube is indicated for pulmonary embolism. • Heart rate irregularity: Not the primary issue; tachycardia is present but rhythm irregularity is not described. • Epigastric pain: Not consistent with the presenting cardiopulmonary emergency.