Exhibits
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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 D
Explanation
D. A weight loss of 1.8 kg (4 lb) in the past 24 hours indicates effective diuresis (urine output) and reduction in fluid volume, which is the therapeutic goal of furosemide in treating pulmonary edema.
A Furosemide is a loop diuretic that typically causes a decrease in blood pressure by promoting the excretion of excess fluid and sodium from the body.
B. Adventitious breath sounds such as crackles (rales) indicate the presence of fluid in the lungs, which is a characteristic finding in pulmonary edema.
C. A respiratory rate of 24 breaths per minute is within normal range for an adult at rest. While this respiratory rate is not abnormal, it also does not directly indicate whether furosemide is effective in treating pulmonary edema.
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