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Medical Emergencies

Stage 5 — Take action. The PE-response team has evaluated the client and therapeutic anticoagulation is prescribed. Place the following nursing actions in the best priority sequence. Closely related steps should be initiated without unnecessary delay.

Ordered Response

Choose your responses, then check the answer.

Reassess oxygenation, hemodynamics, chest symptoms, and bleeding; prepare for urgent advanced therapy if the client deteriorates
Maintain continuous cardiac and pulse-oximetry monitoring; verify IV access, allergies, CBC, platelet count, renal function, and bleeding-risk findings
Document the response, medication administration, reassessments, team communication, and transfer or handoff plan
Continue prescribed oxygen, position for ease of breathing, and immediately reassess SpO2, respiratory effort, BP, and mental status
Administer the prescribed therapeutic anticoagulant using the agent-specific protocol and an independent safety check when required
Explanation
Best priority sequence
1) Continue oxygen and perform an immediate ABC-focused reassessment. 2) Maintain continuous monitoring and verify the safety data needed for the ordered anticoagulant. 3) Administer anticoagulation using the agent-specific protocol. 4) Reassess for improvement, deterioration, and bleeding while preparing to escalate if needed. 5) Complete documentation and handoff. The first three steps occur in rapid succession and should not be interpreted as permission to delay monitoring, team communication, or treatment.
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For study reference only. Always follow current clinical guidelines and your institution’s protocols.

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