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":"E"}
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 {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices:
- Compartment syndrome: The client shows hallmark signs: pain unrelieved by medication (rated 9/10), cool foot, 2+ edema, numbness, absent pedal pulses, delayed capillary refill, and inability to move the foot. These findings indicate increased pressure within a muscle compartment that compromises circulation and nerve function, requiring emergency intervention to prevent tissue necrosis or amputation.
- Osteomyelitis: A rapidly rising temperature (up to 38.9°C), elevated WBC count (28,000/mm³), and presence of drainage from the splint site suggest a localized bone infection. Osteomyelitis can develop from an open fracture, especially post-surgery, and early detection is critical for avoiding systemic infection or bone destruction.
Rationale for Incorrect Choices:
- Deep vein thrombosis (DVT): While immobilization increases DVT risk, the scenario lacks classic signs like unilateral calf swelling, warmth, erythema, or a positive Homan's sign. Additionally, pulses are absent in the foot, not consistent with a DVT presentation, which typically does not affect distal pulses.
- Fat embolism: The client does not exhibit hallmark signs such as acute respiratory distress, petechial rash, or altered mental status. Although long bone fractures pose a fat embolism risk, no findings suggest embolic movement or pulmonary compromise in this case.
Correct Answer is A
Explanation
Rationale:
A. Assess the client's peripheral pulses every 15 min: Frequent assessment of peripheral pulses is essential to monitor for signs of arterial obstruction, bleeding, or hematoma formation at the femoral site. This helps ensure adequate perfusion and detect complications early.
B. Elevate the head of the client's bed to 45°: After femoral catheterization, the head of the bed should be elevated no more than 30° to reduce pressure at the puncture site and prevent bleeding. A 45° angle may increase the risk of hemorrhage.
C. Change the client's dressing 4 hr following the procedure: The dressing should remain in place and be monitored for signs of bleeding or saturation. Routine dressing changes shortly after the procedure are not recommended unless soiled or ordered.
D. Instruct the client to flex the right knee every 30 min: Flexing the leg increases the risk of dislodging the clot or reopening the arterial puncture site. The affected leg should remain straight and immobilized for several hours post-procedure.
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