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Exhibits

Click to highlight the findings that require follow up.

Neurological: Alert and oriented. Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Gastrointestinal: Within normal limits (WNL).

Genitourinary: WNL

Musculoskeletal: WNL

Pain: 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

Alert and oriented

chest pain described as pressure and tightness that is unrelieved with rest

Radial and pedal pulses 2+

Capillary refill 2 seconds

Rapid and shallow breaths

Clear breath sounds throughout bilateral lungs

7 on a 0 to 10 scale, tightness and pressure in chest

Answer and Explanation

The Correct Answer is ["B","E","G"]

Chest pain described as pressure and tightness that is unrelieved with rest: Chest pain that is described as tightness and pressure, particularly when unrelieved by rest, is a classic presentation of acute coronary syndrome (ACS), which includes conditions such as unstable angina or myocardial infarction (MI). This is a red flag symptom, as it indicates a need for immediate medical attention to rule out life-threatening conditions like MI, which can be fatal without timely intervention.

Rapid shallow breaths: Rapid and shallow breathing can be a response to acute pain, particularly in a situation involving cardiovascular stress. It may be indicative of the body's attempt to compensate for inadequate oxygenation due to cardiac ischemia, hypoxia, or anxiety.

Pain 7/10, tightness and pressure in the chest: A pain rating of 7/10 demands immediate evaluation and management, as it could indicate an evolving cardiovascular event. Moreover, tightness and pressure are specific descriptors of pain seen in ischemic heart disease, where there is reduced blood flow to the heart muscle, leading to discomfort due to oxygen deprivation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Auscultation is generally used to assess bowel sounds or lung sounds, not urinary retention.

B. Measuring girth may be useful for assessing ascites or other fluid retention but is not specific to urinary retention.

C. Observing the appearance of urine is not directly useful for detecting retention. Retention is about the inability to void despite the urge, and urine may or may not be visibly affected.

D. Palpation above the pubic symphysis is the most effective way to assess for urinary retention because the bladder is located in this area. A distended bladder, which is a sign of retention, can often be palpated here.

A. Give diphenhydramine prep for intravenous pyelogram. B. Obtain clean catch urine for culture and sensitivity. C. Force oral fluids to 2,000 mL/24 hours. D. Initiate broad spectrum IV antibiotic as secondary infusion. E. Collect a serum sample for hemoglobin and hematocrit.

Correct Answer is ["B","D"]

Explanation

A. Diphenhydramine is unnecessary for diagnosing pyelonephritis.
B. Urine culture confirms bacterial infection and guides antibiotic therapy.
C. Forcing fluids may help but is not the priority over antibiotics and cultures.
D. Broad-spectrum IV antibiotics are critical to treat systemic infection.
E. Hemoglobin and hematocrit are not priority tests for pyelonephritis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is D

Explanation

An adult is admitted with acute flank pain, a 102° F (38.9° C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.

Correct Answer is ["B","D"]

Explanation

Patient Data Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving an epidural anesthesia.

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Exhibits Which laboratory tests would be helpful in determining the plan of care for this client? Select all that apply.

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The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

Exhibits Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions. Drag from the Word Choices to complete the sentence. The client demonstrates effective epidural anesthesia by dropdown, dropdown, and dropdown.

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?