A 76-year-old patient is 2 days post-op total hip replacement. The patient puts his call light on to complain of difficulty catching his breath. As the nurse assesses the patient, she finds the patient tachypneic, tachycardic, and very anxious. The nurse determines these are most likely signs of:

Pulmonary embolism

Left-sided heart failure

Early onset dementia

Acute myocardial infarction

Answer and Explanation

The Correct Answer is A

Choice A reason: Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. The signs and symptoms include sudden shortness of breath, rapid breathing (tachypnea), rapid heart rate (tachycardia), and anxiety. These symptoms align with the patient's presentation and are common in the post-operative period, particularly after orthopedic surgery, which increases the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism.

Choice B reason: Left-sided heart failure can cause symptoms such as shortness of breath, fatigue, and fluid retention. However, the acute presentation of difficulty breathing, tachypnea, tachycardia, and anxiety in the context of recent surgery is more suggestive of a pulmonary embolism. Heart failure symptoms generally develop gradually rather than suddenly.

Choice C reason: Early onset dementia is not characterized by acute respiratory symptoms like difficulty breathing, tachypnea, or tachycardia. Dementia symptoms typically include memory loss, confusion, and changes in cognitive function, not the acute cardiorespiratory symptoms described in this scenario.

Choice D reason: Acute myocardial infarction (heart attack) can cause shortness of breath, chest pain, and rapid heart rate. While it is a possibility, the combination of recent surgery and the described symptoms more strongly suggests a pulmonary embolism. An acute myocardial infarction would typically also present with chest pain, which is not mentioned in this scenario.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C"]

Explanation

Choice A reason: Auscultating for irregular heart tones can provide useful information about the heart’s rhythm and potential arrhythmias. However, it is not the most specific or definitive assessment for diagnosing a myocardial infarction (MI).

Choice B reason: Assessing for ST elevations on continuous telemetry and 12-lead EKG is critical in diagnosing a myocardial infarction. ST-segment elevation is a key indicator of an acute MI, specifically indicating myocardial injury. Continuous telemetry and 12-lead EKG provide real-time and detailed views of the heart's electrical activity, helping to identify ischemic changes.

Choice C reason: Assessing for elevated Troponin levels is essential because Troponins are cardiac biomarkers that increase significantly when there is damage to the heart muscle, such as during an MI. Elevated Troponin levels are highly specific and sensitive indicators of myocardial infarction, making this assessment crucial.

Choice D reason: Assessing for low magnesium levels is not directly related to diagnosing a myocardial infarction. While magnesium levels are important for overall cardiac function, they do not specifically indicate an acute MI.

Choice E reason: Assessing the client's blood pressure is an important part of a comprehensive assessment and can provide information about the patient's hemodynamic status. However, it is not specific to diagnosing a myocardial infarction.

Choice F reason: Assessing if the pain radiates to the left arm is an important symptom of a myocardial infarction. However, while it supports the suspicion of an MI, it is not as definitive as ST elevation on an EKG or elevated Troponin levels.

A. Analgesic properties without sedation. B. Vasoconstriction and improved blood flow. C. Platelet inhibition to reduce clot formation. D. Cardiotonic properties and improved contraction.

Correct Answer is C

Explanation

Choice A reason: Aspirin does have analgesic properties, which help relieve pain. However, this is not the primary reason for its administration in the context of angina-like chest pain. The analgesic effect of aspirin without sedation is more relevant in the management of general pain or headaches.

Choice B reason: Vasoconstriction and improved blood flow are not effects of aspirin. In fact, aspirin's mechanism of action involves preventing platelet aggregation, which can indirectly improve blood flow by reducing the risk of clot formation. Vasoconstriction is not an effect associated with aspirin.

Choice C reason: The primary rationale for administering aspirin to a client with angina-like chest pain is its antiplatelet effect. Aspirin inhibits platelet aggregation, reducing the risk of clot formation. This is crucial in preventing further blockage of coronary arteries, which can exacerbate angina or lead to myocardial infarction.

Choice D reason: Cardiotonic properties and improved contraction are not associated with aspirin. Cardiotonic drugs enhance the strength of the heart's contractions, which is not an action of aspirin. Aspirin's role in this context is to prevent platelet aggregation and reduce the risk of clot-related complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A 76-year-old patient is 2 days post-op total hip replacement. The patient puts his call light on to complain of difficulty catching his breath. As the nurse assesses the patient, she finds the patient tachypneic, tachycardic, and very anxious. The nurse determines these are most likely signs of:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following cues should the nurse assess to determine if the client is experiencing a myocardial infarction? Pick 2 answers.

Correct Answer is ["B","C"]

Explanation

The nurse correlates which rationale with the administration of aspirin to the client experiencing angina-like chest pain?

Correct Answer is C

Explanation

A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving vasopressin (Desmopressin). The nurse understands the therapeutic outcome is a decrease in:

A nurse cares for a patient recovering from mechanical valve replacement surgery. The patient asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse?

The nurse has completed an assessment on a client with heart failure and a decreased cardiac output with an ejection fraction of 30%. Which finding should receive the highest priority?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

Which client should the telemetry nurse assess first after receiving the a.m. shift report?

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders: Select all that apply.