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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. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.

B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.

C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.

D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.

A. Wear a dosimeter film badge to measure exposure. B. Discard bed linens from the client's room at the end of each day. C. Instruct visitors to remain 61 cm (2 feet) away from the client. D. Place a caution sign on the client's door. E. Don a lead apron when providing care.

Correct Answer is ["A","D","E"]

Explanation

Rationale:

A. Wear a dosimeter film badge to measure exposure: A dosimeter badge tracks the cumulative radiation exposure for healthcare workers. It is essential for staff safety when caring for clients with internal radiation therapy.

B. Discard bed linens from the client's room at the end of each day: Linens should not be discarded unless contaminated. They are usually kept in the room until radiation is removed to avoid unnecessary exposure to other staff or areas.

C. Instruct visitors to remain 61 cm (2 feet) away from the client: Visitors should maintain a greater distance typically at least 6 feet (about 2 meters) and limit their visit time (usually to 30 minutes or less). Two feet is insufficient to minimize radiation exposure.

D. Place a caution sign on the client's door: Posting a radiation warning sign helps alert all personnel and visitors about radiation precautions, promoting safety and compliance with guidelines.

E. Don a lead apron when providing care: A lead apron protects the nurse from radiation exposure, especially when prolonged or close contact is necessary. It is a critical part of personal protective equipment in this setting.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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