A nurse on a step-down unit is admitting a client.
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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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Identify possible precipitating factors related to the infections: The first step in addressing a quality or safety concern is to assess the situation and collect data. Identifying contributing factors helps guide appropriate interventions and ensures that any subsequent actions are targeted and evidence-based.
B. Meet with providers to discuss measures to decrease the infections: Collaborating with providers is essential for implementing effective solutions, but this step should follow a thorough assessment. Without identifying root causes first, discussions may be unfocused or ineffective in reducing infection rates.
C. Schedule nursing staff training for infection control procedures: Training is a critical part of reducing catheter-associated infections, especially if staff knowledge gaps are discovered. However, education should be informed by a needs assessment and data on what factors are contributing to the infections.
D. Revise the current policy for catheter care: Policy revision may be necessary if current guidelines are outdated or inadequate. However, revising policy prematurely, without understanding the source of the problem, may lead to unnecessary or ineffective changes.
Correct Answer is B
Explanation
Rationale:
A. Fidelity: Fidelity involves loyalty, faithfulness, and keeping promises to individuals. While important in one-on-one nursing relationships, it is not the guiding principle when planning for population-wide benefit.
B. Utilitarianism: Utilitarianism is an ethical principle focused on producing the greatest good for the greatest number of people. It is most appropriate when planning community programs that aim to maximize overall health benefits.
C. Autonomy: Autonomy emphasizes respecting individual rights and decision-making. While vital in personal healthcare decisions, it does not directly guide broad community health program planning.
D. Veracity: Veracity refers to truth-telling and honesty in communication. Although essential in client interactions, it does not provide direction in choosing programs that broadly benefit the community.
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