Try Naxlex NCLEX-RN (Free-Trial)

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

Exhibits

Drag words from the choices below to fill in each blank in the follow sentence.

The client is at risk for developing

and .
Answer and Explanation

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

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.

Correct Answer is C

Explanation

Rationale:

A. A client who requests assistance to use the bedside commode: This is a routine activity that falls within the scope of practice for assistive personnel. As long as the AP follows standard safety procedures, there is no immediate need to report this to the nurse.

B. A client who requests to sit in the bedside chair while watching TV: Allowing a client to sit up in a chair is within the AP’s role, provided the client is stable and fall precautions are followed. It does not require nurse notification unless there are complications.

C. A client who has a prescription for compression stockings and did not receive them: This indicates a potential lapse in prescribed therapy, which could increase the risk of complications like deep vein thrombosis. The nurse must be informed to evaluate and correct the omission promptly.

D. A client who consumes all the food from their meal tray: Reporting full meal consumption is not necessary unless the client is on a monitored diet or has specific nutritional concerns. In most cases, this is expected and requires only standard documentation.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register