Exhibits
Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.
Nurses' Notes
1000:
Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.
Client reports tightness in chest that radiates to left arm
States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast
Client is diaphoretic and short of breath
Heart rate irregular and tachycardic
I had scrambled eggs and bacon like I do every morning
Lungs clear to auscultation in all lobes
+1 pedal pulses
Capillary refill less than 2 seconds
The Correct Answer is ["A","B","C","D"]
Client reports tightness in chest that radiates to left arm: Chest tightness that radiates to the left arm is a classic symptom of myocardial ischemia or infarction (heart attack). This symptom is concerning because it suggests potential heart muscle damage or decreased blood flow to the heart.
States pain as 7 on a scale of 0 to 10: The client rates their chest pain as 7 out of 10. This indicates significant discomfort and suggests that the chest tightness is causing substantial pain. Pain severity is an important indicator in assessing the severity of the cardiac event.
Started to feel nauseous after breakfast: Nausea can be a symptom associated with myocardial ischemia or infarction, particularly when it occurs after physical exertion or a meal. It can be caused by decreased blood flow to the gastrointestinal tract due to compromised cardiac function.
Client is diaphoretic and short of breath: Diaphoresis (excessive sweating) and shortness of breath are additional symptoms that commonly accompany acute myocardial infarction. Diaphoresis occurs due to sympathetic nervous system activation, while shortness of breath can result from decreased cardiac output or pulmonary congestion.
Heart rate irregular and tachycardic: An irregular and tachycardic (rapid) heart rate is abnormal and suggests cardiac dysrhythmia, which can occur in response to myocardial ischemia or infarction. It reflects the heart's attempt to compensate for reduced oxygen delivery to the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Instructing the client not to bend the affected leg helps prevent accidental dislodgement of the arterial sheath or catheter and reduces the risk of bleeding or hematoma formation at the insertion site.
A While monitoring vital signs is important, doing so once every hour is not specified as a standard post- procedure action.
B. Elevating the head of the bed to a 45° angle and restricting fluid intake are not standard care measures following this procedure and could potentially be contraindicated.
C. This action is not typically necessary following a cardiac catheterization unless there are specific indications such as fluid overload or impaired renal function
Correct Answer is B
Explanation
B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.
A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.
C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.
D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.