Question

A patient is admitted to Emergency room suffering of pulmonary embolism what would be the expected treatment?

Answer 1

Correct Answers:

Start anticoagulation intravenously

Rationale :

🔶 IV anticoagulation (usually IV heparin) is the immediate first-line therapy for pulmonary embolism because it rapidly prevents further clot formation.

🔶 Heparin has a fast onset, making it ideal during life-threatening clot events.

🔶 Allows transition to oral anticoagulants once the patient is stabilized.

🔶 Reduces mortality and recurrence risk, which is highest in the first hours to days.

🔶 IV dosing allows titration, based on aPTT, ensuring safe therapeutic ranges.

🔶 Start steroids

– Steroids have no role in treating PE.

– They do not dissolve or prevent clots.

🔶 Start anticoagulation by mouth

– Oral agents have slow onset and are not used for initial emergency treatment.

– Cannot rapidly stabilize a patient.

🔶 Start diuretics

– Diuretics do not treat clots.

– They may worsen hypotension in PE.

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Answer 2

Correct Answers:

Hypotension, JVD, muffled heart sounds

Rationale :

✨ This triad is Beck’s triad, the hallmark of acute tamponade.

✨ Hypotension occurs because pericardial fluid restricts ventricular filling.

✨ Jugular venous distention reflects impaired right-sided return.

✨ Muffled heart sounds occur due to fluid surrounding the heart.

✨ These signs indicate life-threatening compression requiring immediate intervention.

✨ Chest pain, fever, pericardial rub – Seen in pericarditis, not tamponade.

✨ Hypertension, bounding pulses, S3 – More consistent with fluid overload.

✨ Syncope, rales, S4 – Nonspecific and not characteristic of tamponade.

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Answer 3

Correct Answers:

Acute arterial occlusion

Rationale :

🔵 The 6 Ps (pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis) indicate acute loss of arterial blood flow.

🔵 This pattern is classic for arterial embolism or thrombosis.

🔵 Rapid ischemia leads to nerve and muscle compromise.

🔵 Time-sensitive diagnosis, requiring emergency revascularization.

🔵 Helps distinguish arterial problems from venous disorders.

🔵 Deep vein thrombosis – Causes swelling and warmth, not pulselessness.

🔵 Cellulitis – Causes redness and warmth, not 6 Ps.

🔵 Chronic venous insufficiency – Causes edema and pigmentation, not acute ischemia.

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Answer 4

Correct Answers:

Provide the client with supplemental oxygen.

Rationale :

🟣 The first priority is improving oxygenation because pulmonary edema impairs gas exchange.

🟣 Hypoxia can rapidly worsen into respiratory failure if oxygen is not given immediately.

🟣 Before medications work, oxygen provides immediate physiologic support.

🟣 Addresses life-threatening dyspnea and tissue hypoxia.

🟣 Oxygen improves saturation while the nurse prepares other interventions.

🟣 Nitroglycerin SL – Helpful but not before ensuring oxygenation.

🟣 Morphine IV – Not first priority; oxygenation comes first.

🟣 High-Fowler’s with legs dependent – Helpful but not the immediate first action.

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Answer 5

Correct Answers:

Elevated Brain Natriuretic Peptide (BNP)and chest X-ray with cardiomegaly and lungs congestion

Rationale :

◆ BNP rises when ventricular wall pressure increases in heart failure.

◆ Cardiomegaly on X-ray reflects chronic heart enlargement.

◆ Pulmonary vascular congestion suggests fluid backing up into lungs.

◆ This combination strongly points to cardiogenic, not noncardiogenic, edema.

◆ These findings support a diagnosis of CHF-related pulmonary edema.

◆ Normal PCWP – PCWP is elevated in cardiogenic pulmonary edema.

◆ Normal LVEF – LVEF is reduced in cardiogenic causes.

◆ PaO₂/FiO₂ <150 with no cardiac enlargement – Indicates ARDS, not CHF.

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Answer 6

Correct Answers:

Routine opioids for dyspnea
Large IV crystalloid boluses
Nonselective beta-blocker initiation in the acute episode

Rationale :

🔥 Routine opioids for dyspnea Opioids reduce respiratory drive, worsening CO₂ retention.

🔥 Can cause hypotension, worsening cardiac output.

🔥 Increase risk of sedation in already hypoxic patients.

🔥 Not first-line therapy for pulmonary edema.

🔥 May delay definitive treatment.

🔥 Large IV crystalloid boluses Increase intravascular volume, worsening pulmonary congestion.

🔥 The failing heart cannot handle extra fluid.

🔥 Raises hydrostatic pressure → more pulmonary edema.

🔥 Contraindicated unless patient is shock (not typical for cardiogenic edema).

🔥 Risk of respiratory collapse.

🔥 Nonselective beta-blocker initiation Negative inotropes can worsen acute decompensation.

🔥 Can cause bronchospasm and worsen perfusion.

🔥 Not started during acute episodes—only resumed when stable.

🔥 Worsens bradycardia and hypotension if present.

🔥 Can further reduce cardiac output.

🔥 Aspirin PO Safe and beneficial in cardiac patients. Has no role in worsened pulmonary edema.

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Answer 7

Correct Answers:

Transthoracic echocardiogram

Rationale :

🌟 Provides direct visualization of cardiac chambers, valves, and movement.

🌟 Determines ejection fraction, the key measure in CHF.

🌟 Detects wall motion abnormalities, hypertrophy, and dilation.

🌟 Assesses severity of systolic vs diastolic dysfunction.

🌟 The most useful, non-invasive test for diagnosing and monitoring heart failure.

🌟 Chest radiograph – Shows congestion, not specific heart function.

🌟 Cardiac MRI – Accurate but not first-line in ER settings.

🌟 Coronary CT angiography – Detects coronary disease, not heart failure function.

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Answer 8

Correct Answers:

Sodium restriction (e.g. -2 g/day) and daily weights

Rationale :

🔷 Sodium restriction decreases fluid retention, reducing preload and preventing worsening congestion.

🔷 2 g/day sodium limit is the standard guideline for stable, chronic HF with volume sensitivity.

🔷 Daily weights detect early fluid accumulation, often before symptoms worsen.

🔷 Prevents hospitalizations by allowing early adjustment of diuretics.

🔷 Reduces risk of edema, pulmonary congestion, and HF decompensation.

🔷 No fluid limits

– HF patients still need monitoring; volume-sensitive patients frequently require limits.

– May cause fluid overload.

🔷 High-protein, high-sodium diet

– High sodium worsens congestion and HF symptoms.

– Not recommended unless patient has cachexia (but still sodium restricted).

🔷 Liberal sodium >4 g/day

– Leads to rapid fluid retention.

– Can precipitate acute HF exacerbation.

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Answer 9

Correct Answers:

Begin unfractionated heparin and consider systemic thrombolysis after excluding absolute contraindications

Rationale :

🟥 Massive PE with shock or severe hypotension is life-threatening and requires immediate treatment.

🟥 UFH is preferred because it has rapid onset and can be stopped quickly if thrombolytics are needed.

🟥 Systemic thrombolysis is indicated when massive PE causes hemodynamic instability and imaging is not possible yet.

🟥 Mortality rates drop significantly when thrombolytics are administered promptly in unstable PE.

🟥 This approach aligns with ACC/AHA and ESC guidelines for massive PE management.

🟥 Schedule V/Q scan tomorrow

– Delays life-saving therapy.

– Unstable patients cannot wait for imaging.

🟥 Start aspirin

– Does not treat pulmonary embolism.

– Provides no anticoagulation or clot-lysis benefit.

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Answer 10

Correct Answers:

Recurrent PE despite therapeutic anticoagulation or absolute contraindication to anticoagulation

Rationale :

🔶 This is the primary guideline-supported indication: either anticoagulation cannot be given OR clot recurs despite correct anticoagulation.

🔶 IVC filters prevent emboli from reaching the lungs, offering mechanical protection when medication is unsafe or ineffective.

🔶 Used when bleeding risk is extremely high, such as active hemorrhage, recent brain surgery, or severe thrombocytopenia.

🔶 Recommended only for severe cases because filters can cause long-term complications (DVT, filter thrombosis).

🔶 Provides immediate protection in unstable patients who cannot safely receive anticoagulants.

🔶 Low D-dimer with low clinical probability

– These patients do not need any PE intervention, much less a filter.

– Low D-dimer essentially rules out PE.

🔶 All first-time PE patients

– Not recommended, as anticoagulation alone is effective in first events.

– Filter would expose them to unnecessary risk.

🔶 After 10 days of heparin in every patient

– No guideline supports routine IVC filter use.

– Completely inappropriate and harmful.

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QUIZ 3 FALL 2025

No.

1 :
A patient is admitted to Emergency room suffering of pulmonary embolism what would be the expected treatment?

2 :
Which triad best characterizes acute cardiac tamponade?

3 :
The 6 Ps" (pain, pallor, pulselessness, paresthesia, poikilothermia , paralysis) point to:

5 :
Which finding is most characteristic of cardiogenic pulmonary edema related to Congestive Heart Failure?

6 :
Medications to use cautiously or avoid in acute decompensated cardiogenic pulmonary edema:

7 :
The nurse is receiving a patient diagnosed with Congestive Heart Failure. Which diagnostic test will be more specific to diagnose the hear changes?

8 :
Most appropriate dietary advice for stable HF with volume sensitivity?

9 :
An unstable patient with suspected massive PE (hypotension, syncope, JVD) cannot leave the ICU for imaging. Best immediate action?

10 :
Indication for IVC filter placement?

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QUIZ 3 FALL 2025

No.

1 : A patient is admitted to Emergency room suffering of pulmonary embolism what would be the expected treatment?

2 : Which triad best characterizes acute cardiac tamponade?

3 : The 6 Ps" (pain, pallor, pulselessness, paresthesia, poikilothermia , paralysis) point to:

5 : Which finding is most characteristic of cardiogenic pulmonary edema related to Congestive Heart Failure?

6 : Medications to use cautiously or avoid in acute decompensated cardiogenic pulmonary edema:

7 : The nurse is receiving a patient diagnosed with Congestive Heart Failure. Which diagnostic test will be more specific to diagnose the hear changes?

8 : Most appropriate dietary advice for stable HF with volume sensitivity?

9 : An unstable patient with suspected massive PE (hypotension, syncope, JVD) cannot leave the ICU for imaging. Best immediate action?

10 : Indication for IVC filter placement?

1 :
A patient is admitted to Emergency room suffering of pulmonary embolism what would be the expected treatment?

2 :
Which triad best characterizes acute cardiac tamponade?

3 :
The 6 Ps" (pain, pallor, pulselessness, paresthesia, poikilothermia , paralysis) point to:

5 :
Which finding is most characteristic of cardiogenic pulmonary edema related to Congestive Heart Failure?

6 :
Medications to use cautiously or avoid in acute decompensated cardiogenic pulmonary edema:

7 :
The nurse is receiving a patient diagnosed with Congestive Heart Failure. Which diagnostic test will be more specific to diagnose the hear changes?

8 :
Most appropriate dietary advice for stable HF with volume sensitivity?

9 :
An unstable patient with suspected massive PE (hypotension, syncope, JVD) cannot leave the ICU for imaging. Best immediate action?

10 :
Indication for IVC filter placement?