A nurse on a step-down unit is admitting a client.
Drag words from the choices below to fill in each blank in the follow sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for Correct Choices:
- Decreased cardiac output: The client is post–myocardial infarction and experiences chest pain with minimal exertion, tachycardia (HR 112/min), and signs of anxiety and fear. These findings suggest that myocardial function may be compromised. Decreased cardiac output is a significant risk in post-MI clients due to potential for reinfarction, ischemia, or left ventricular dysfunction.
- Respiratory failure: The client has COPD, an elevated respiratory rate (32/min), and oxygen saturation of 87% on room air, which indicates significant hypoxemia. The productive cough, fatigue, and shortness of breath increase the risk for decompensation into respiratory failure without prompt oxygen therapy and pulmonary support.
Rationale for Incorrect Choices:
- Pancytopenia: This condition involves a reduction in red blood cells, white blood cells, and platelets. There is no evidence of bone marrow suppression, recent chemotherapy, or hematologic disorder in this client’s history.
- Neurogenic shock: Neurogenic shock results from spinal cord injury or disruption of sympathetic nervous system control. The client has no evidence of trauma or spinal pathology, and the elevated heart rate contradicts the expected bradycardia of neurogenic shock.
- Hepatic encephalopathy: This is caused by liver dysfunction, typically in clients with advanced liver disease. There are no signs of altered mental status, liver disease, or elevated ammonia levels in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Initiate fundal massage: Fundal massage is performed after delivery to prevent or manage uterine atony and postpartum hemorrhage. It is not appropriate during active labor, especially before the birth of the fetus.
B. Apply a fetal heart rate monitor: After rupture of membranes, there is an increased risk of umbilical cord prolapse or fetal distress. Continuous fetal monitoring is essential to assess fetal well-being and detect complications promptly.
C. Insert an indwelling urinary catheter: While catheterization may be done later, especially before epidural placement or cesarean delivery, it is not the most urgent action. It does not address immediate risks associated with ruptured membranes.
D. Initiate an oxytocin IV infusion: Oxytocin is used to augment or induce labor, but should not be started without first assessing fetal status. Fetal monitoring is necessary to establish a baseline before initiating uterotonic agents.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Rationale:
- Insert a nasogastric tube and maintain low intermittent suction: This is anticipated to help decompress the stomach, reduce nausea and vomiting, and prevent aspiration in a client with severe pancreatitis who is vomiting and has abdominal distension.
- Administer IV lactated Ringer's: IV fluids are critical for hydration and to correct electrolyte imbalances in acute pancreatitis. Lactated Ringer’s is preferred over normal saline because it better maintains acid-base balance.
- Insert an indwelling urinary catheter: This is generally contraindicated unless necessary, as it increases the risk of infection. No information indicates urinary retention or need for strict output monitoring that outweighs infection risks.
- Administer IV famotidine: Famotidine reduces gastric acid secretion, which helps protect the gastric mucosa and may be beneficial in preventing stress ulcers in critically ill clients. It is appropriate in this situation.
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