A practical nurse is monitoring a client who was recently admitted with a deep vein thrombosis (DVT) in the left lower extremity. Which new clinical finding should the nurse identify as the highest priority to report to the charge nurse immediately?
- Sudden onset of tachypnea, a dry cough, and feelings of apprehensionAnswer
- BA steady, dull aching pain in the affected calf that worsens with movement
- CDevelopment of 2+ pitting edema and mild erythema around the left ankle
- DThe affected lower extremity feeling significantly warmer to the touch than the right
Answer
The sudden onset of tachypnea, a dry cough, and feelings of apprehension indicates a medical emergency.
The development of sudden tachypnea (rapid breathing), a dry cough, and apprehension in a client with a DVT strongly suggests a pulmonary embolism (PE). A PE occurs when a portion of the clot breaks off and travels to the lungs, compromising airway and breathing. According to the ABC (Airway, Breathing, Circulation) framework, this is a life-threatening medical emergency requiring immediate intervention and reporting.
Step-by-Step Solution
Key Concept
Prioritization of care and recognition of pulmonary embolism as a complication of DVT