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A nurse on a step-down unit is admitting a client.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again
Nurses' Notes
Day 3, 1350:
Client transferred to step-down unit from ICU for continued care following a myocardial infarction (MI) 2 days ago. Oriented to room. Client reports a productive cough, States they are short of breathand that ambulating to the bathroom has resulted in chest pain. Reports pain as 3 on a scale of 0 to 10. Client appears anxious and reports a fear of dying.

Oriented to room.

Client reports a productive cough

States they are short of breathand that ambulating to the bathroom has resulted in chest pain.

Reports pain as 3 on a scale of 0 to 10.

Client appears anxious and reports a fear of dying.

Answer and Explanation

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

Rationale for Correct Findings:

Productive cough: In a client with COPD and recent MI, this may signal infection or fluid overload, especially if paired with fever, dyspnea, and hypoxia. Immediate assessment is needed to rule out pneumonia or heart failure.
Shortness of breath and chest pain with ambulation: This raises concern for myocardial ischemia, reinfarction, or worsening heart function. Chest pain with minimal exertion post-MI demands prompt evaluation and possible ECG and oxygen therapy.
Anxiety and fear of dying: Sudden intense fear may indicate worsening hypoxia, cardiac distress, or even be a prodrome to another MI. It should not be dismissed as purely psychological, especially in the context of other concerning symptoms.

Rationale for Incorrect Findings:

Pain rated 3/10: A mild pain score suggests the discomfort is currently manageable. While chest pain after MI is always important, this level does not in itself indicate an emergency unless it worsens or is unrelieved.
Oriented to room: Being alert and oriented indicates preserved cognition and neurologic stability. No immediate follow-up is needed based on this observation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Provide humidification of the room air: Xerostomia, or dry mouth, often results from radiation therapy to the head and neck region. Humidifying room air adds moisture to the environment, helping relieve oral dryness and improving comfort, especially during sleep.

B. Suggest rinsing his mouth with an alcohol-based mouth wash: Alcohol-based mouthwashes can worsen oral dryness and irritate mucosal tissues, making xerostomia more uncomfortable. Clients should instead use alcohol-free or moisturizing rinses.

C. Instruct the client on the use of esophageal speech: Esophageal speech is a communication method taught to clients after laryngectomy, not for xerostomia. It does not address dry mouth and is unrelated to the effects of mandibular radiation.

D. Offer the client saltine crackers between meals: Saltine crackers are dry and salty, which can exacerbate oral dryness and discomfort. Clients with xerostomia benefit more from moist, soft foods and frequent sips of water.

A. Methylprednisolone B. Ondansetron C. Guaifenesin D. Amoxicillin

Correct Answer is A

Explanation

Rationale:

A. Methylprednisolone: Methylprednisolone is a corticosteroid, which can increase blood glucose levels by promoting gluconeogenesis and reducing insulin sensitivity. Hyperglycemia is a known adverse effect, especially with prolonged or high-dose use.

B. Ondansetron: Ondansetron is an antiemetic used to control nausea and vomiting. It does not affect glucose metabolism and is not associated with elevated blood glucose as a side effect.

C. Guaifenesin: Guaifenesin is an expectorant that thins mucus to improve airway clearance. It has no effect on blood sugar levels and is not known to interfere with glucose regulation.

D. Amoxicillin: Amoxicillin is a broad-spectrum antibiotic and does not typically cause changes in blood glucose. It is generally well-tolerated in terms of metabolic side effects.

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