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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Rationale:

A. Nurses notes are used to create the critical pathway: Critical pathways are developed from evidence-based clinical guidelines and best practices, not directly from nurses’ notes. While documentation may help track progress, it is not the foundation for pathway creation.

B. Critical pathways should reduce health care costs: Critical pathways standardize care for specific diagnoses, promoting timely interventions and reducing unnecessary treatments or delays. This efficiency helps lower healthcare costs while improving patient outcomes.

C. Critical pathways have an unlimited timeframe for completion: Each critical pathway includes a defined timeline with expected outcomes for each phase of care. This structure ensures care is efficient and progress is monitored closely to prevent delays or complications.

D. Nurses should discontinue the critical pathway if variances occur: Variances are deviations from the expected outcomes and are used to evaluate and adjust care. They do not justify discontinuing the entire pathway but rather indicate a need for reassessment or individualized modifications.

A. Attach a single-line administration set B. Prime the tubing with 0.9% sodium chloride. C. Use an IV catheter that is at least 24-gauge. D. Use tubing that does not have a filter in the drip chamber.

Correct Answer is B

Explanation

Rationale:

A. Attach a single-line administration set: A blood transfusion requires a Y-type tubing with a filter and two lines—one for the blood and one for normal saline—to allow flushing and compatibility. A single-line set is inadequate.

B. Prime the tubing with 0.9% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime blood tubing, as it is compatible with blood products and prevents clotting or hemolysis. Dextrose or other solutions can cause cell lysis.

C. Use an IV catheter that is at least 24-gauge: A 24-gauge catheter is too small for routine blood transfusions. A larger bore, such as 18- to 20-gauge, is recommended to reduce the risk of hemolysis and allow adequate flow.

D. Use tubing that does not have a filter in the drip chamber: Blood transfusion sets must include a filter (usually 170–260 microns) to trap clots and debris. Using tubing without a filter increases the risk of transfusion reactions.

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Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	dropdown
Cardiovascular	dropdown
Genitourinary	dropdown
Gastrointestinal	dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?

Correct Answer is B

Explanation

A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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