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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.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Rationale:

  • Monitor for elevated temperature: Epidural anesthesia can mask symptoms of infection such as chorioamnionitis. Monitoring temperature helps detect early signs of infection or epidural-related complications.
  • Assess for urinary retention: Epidural anesthesia often causes loss of bladder sensation, increasing the risk for urinary retention. Regular assessments are needed to determine when catheterization is required.
  • Assist the client with ambulation: After epidural anesthesia, lower limb motor function may be impaired. Ambulation is unsafe due to the risk of falls and injury; bedrest is generally advised until full motor function returns.
  • Inform the client to expect drowsiness: Drowsiness is not a typical side effect of epidural anesthesia; it may indicate systemic absorption or another issue. Encouraging drowsiness may mask concerning symptoms that need prompt evaluation.
  • Encourage the client to turn from side to side: Repositioning helps maintain optimal uteroplacental perfusion and prevents hypotension caused by vena cava compression from aortocaval syndrome.

Correct Answer is B

Explanation

Rationale:

A. Match the client's blood type with the type and cross match specimen: While matching blood types is important, autologous transfusions use the client’s own blood, making crossmatching less critical. This step doesn't confirm the identity of the client receiving the blood.

B. Ensure that the client's identification band matches the number on the blood unit: This is the safest and most accurate method to confirm that the blood product belongs to the correct client. The ID band and blood unit must match exactly to prevent transfusion errors.

C. Confirm the provider's prescription matches the number on the blood component: The prescription ensures the correct blood product is ordered, but it doesn't verify client identity. This step should follow positive client identification, not replace it.

D. Ask the client to state his blood type and the date of the blood donation: Clients may not recall this information accurately, and relying on verbal confirmation can lead to errors. Always verify using the ID band and blood label.

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