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
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["A","B","C","D","E"]
Explanation
Dressing is dry and intact with no signs of bleeding or infection: A clean, dry, intact incision with no drainage, erythema, or swelling indicates proper wound healing and a low risk of post-operative infection. Post-appendectomy clients must be assessed for potential wound complications like dehiscence (wound reopening) or infection (redness, purulent drainage, warmth). Since no abnormalities are reported, the client’s surgical site is healing well, supporting discharge readiness.
Successfully advanced from clear liquids to a soft diet without issues: After surgery, clients are started on a clear liquid diet to assess tolerance. If no nausea, vomiting, or bloating occurs, they progress to a soft diet before discharge. Tolerance to oral intake ensures the gastrointestinal (GI) tract is functioning and that the client can maintain adequate nutrition and hydration at home.
Client has ambulated around the unit and tolerated activity well: Early ambulation after surgery is crucial in preventing complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), and postoperative ileus (temporary bowel paralysis). Tolerating ambulation means the client can move independently, reducing the risk of complications related to prolonged bed rest, such as muscle deconditioning and respiratory complications.
Bowel sounds are present in all four quadrants, and the client has passed flatus: The presence of bowel sounds in all quadrants and the passage of flatus (gas) are key indicators that the intestines are resuming normal function after surgery.
Postoperative ileus, a common complication after abdominal surgery, can delay discharge if present. The return of bowel function suggests that the GI system is recovering appropriately, allowing the client to eat and digest food normally.
Pain is well-controlled with oral analgesia: Pain control is an essential criterion for discharge. The client must be able to manage discomfort at home with prescribed oral medications. The ability to tolerate oral analgesics (instead of IV pain management) means the client is independent of hospital-based interventions, making home recovery feasible.
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