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

Exhibits

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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.

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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Rationale:

A. "My home has running water and electricity": Access to utilities like water and electricity supports hygiene and food safety. This statement does not indicate a health risk and instead suggests a stable living environment.

B. “I wear a hat and long sleeves while I am working”: Wearing protective clothing helps reduce exposure to the sun, pesticides, and other environmental hazards, thereby promoting health and safety during outdoor labor.

C. “I am currently sharing my home with two roommates”: Sharing housing is common among migrant or seasonal workers. While crowding can pose a potential health risk, this specific scenario doesn’t indicate excessive crowding or direct danger.

D. “I eat vegetables directly from the field where I work”: Consuming unwashed produce from the field poses a significant risk for pesticide exposure and ingestion of harmful microbes. This practice is unsafe and could lead to acute or chronic health issues.

A. Place the oxygen tank away from curtains or drapes. B. Store the oxygen tank wrench in a locked cabinet. C. Ensure that the client checks the gauge weekly. D. Have the client store smaller tanks under his bed.

Correct Answer is A

Explanation

Rationale:

A. Place the oxygen tank away from curtains or drapes: Oxygen supports combustion, so tanks must be kept away from flammable materials such as curtains or drapes. This placement reduces fire risk and ensures safe home oxygen use.

B. Store the oxygen tank wrench in a locked cabinet: The tank wrench should remain attached to or easily accessible near the tank for emergency shut-off. Locking it away could delay quick responses during equipment malfunction or fire hazards.

C. Ensure that the client checks the gauge weekly: Oxygen tank levels should be checked daily to prevent running out unexpectedly. Waiting a week between checks increases the risk of the tank depleting before a refill is arranged.

D. Have the client store smaller tanks under his bed: Storing tanks under the bed poses a fire hazard due to limited ventilation and proximity to bedding. Oxygen tanks should be stored upright in a secure, well-ventilated area away from heat sources.

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