A patient on prolonged bedrest following a pelvic fracture becomes dyspneic and confused. Pulse = 135 beats/minute, blood pressure = 90/50 mmHg, respirations = 36/minute, Oxygen saturation starts dropping rapidly. Which of the following conditions should the nurse prepare to treat for this patient?

Anxiety attack

Pneumonia

Pulmonary embolism

Asthma exacerbation

Answer and Explanation

The Correct Answer is C

A. While anxiety can cause rapid breathing and confusion, the patient's clinical presentation (dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation) is more consistent with a serious physical condition, such as a pulmonary embolism, rather than an anxiety attack.

B. Pneumonia could cause dyspnea and confusion, but the rapid onset of symptoms, along with the patient's history of prolonged bed rest and risk factors, suggests a pulmonary embolism rather than pneumonia.

C. Pulmonary embolism (PE) is a life-threatening condition that can occur in patients on prolonged bedrest, especially after a pelvic fracture. The patient’s symptoms of dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation are classic signs of PE. This requires immediate intervention, including anticoagulation and possibly thrombolytic therapy.

D. Asthma exacerbation typically presents with wheezing and difficulty breathing, but it would not typically cause the severe hypotension, confusion, and rapid oxygen desaturation seen in this patient.

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Correct Answer is B

Explanation

A. Rhonchi are low-pitched, coarse sounds heard during both inspiration and expiration. They are typically associated with mucus or secretions in the larger airways and do not match the description of high-pitched squeaking sounds.

B. Wheezes are high-pitched, continuous sounds heard primarily during expiration. They result from narrowed airways, which are characteristic of asthma. The description provided matches wheezes, making this the correct documentation.

C. Stridor is a high-pitched sound heard predominantly during inspiration and is associated with upper airway obstruction. It does not match the description of sounds heard during exhalation.

D. Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli or smaller airways. They do not match the high-pitched squeaking sounds described.

A. Buck's extension traction will reduce the fracture. B. Buck's extension traction will maintain alignment of the pins. C. Buck's extension traction will relieve muscle spasms. D. Buck's extension traction will allow supported movement of the extremity.

Correct Answer is C

Explanation

A. Buck's extension traction is not used to reduce fractures but to provide comfort, maintain alignment, and reduce muscle spasms in the affected area. Reduction of the fracture typically occurs through surgical intervention.

B. Buck's extension traction is not used to maintain the alignment of pins, as there are no pins involved in this type of traction. It is designed to relieve muscle spasms and provide comfort to the affected limb.

C. Buck's extension traction is primarily used to relieve muscle spasms and provide a steady pull on the affected limb to maintain alignment and reduce pain. This is particularly important in hip fractures to prevent further injury and discomfort.

D. Buck's extension traction does not allow for supported movement of the extremity; instead, it helps to immobilize the limb and reduce muscle spasms.

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A patient on prolonged bedrest following a pelvic fracture becomes dyspneic and confused. Pulse = 135 beats/minute, blood pressure = 90/50 mmHg, respirations = 36/minute, Oxygen saturation starts dropping rapidly. Which of the following conditions should the nurse prepare to treat for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

Correct Answer is B

Explanation

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?

Correct Answer is C

Explanation

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