Exhibits
A nurse is reviewing the client’s condition. Based on the exhibits provided, what is the most likely diagnosis for this client?
. Hypovolemic shock and Puerperal infection
. Pulmonary embolism and postpartum hemorrhage
Acute myocardial infarction and postpartum hemorrhage
Pneumonia and Acute myocardial infarction
The Correct Answer is B
The most likely diagnosis for this client is B. Pulmonary embolism and postpartum hemorrhage.
Here’s why:
- Postpartum Hemorrhage:
- The client has a large amount of lochia rubra, indicating significant blood loss.
- Hemoglobin and hematocrit levels are low (7.5 g/dL and 22%, respectively), which is consistent with significant blood loss.
- Symptoms like feeling lightheaded, pale appearance, and cool, clammy skin further support this diagnosis.
- Pulmonary Embolism:
- The client is experiencing shortness of breath, using accessory muscles to breathe, and has an oxygen saturation of 88% on room air.
- Elevated D-dimer levels (1.5 µg/mL) suggest the presence of a clot.
- Arterial Blood Gas (ABG) results show a low PaO2 (60 mmHg) and a slightly acidic pH (7.32), which can be seen in pulmonary embolism.
- The client reports a feeling of tightness in her chest and has a rapid heart rate (120 beats per minute), which are also indicative of a pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While teaching the client about infection prevention measures is important, it is not the most immediate priority in this situation. The client is already potentially contagious, and these measures may not be sufficient to prevent transmission if the client is not properly isolated.
It's crucial to remember that the client may be experiencing cognitive impairment due to illness, making it harder to fully comprehend and adhere to instructions.
Additionally, some clients may not have access to or be able to afford masks and hand sanitizer, potentially hindering compliance with these measures.
Choice B rationale:
Isolating the client is the most critical action to prevent the spread of COVID-19 to others. This includes separating the client from other patients, family members, and healthcare workers who are not wearing proper PPE.
PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the client, minimizing the risk of transmission via direct contact or droplets.
Proper isolation techniques include placing the client in a designated negative-pressure isolation room, if available, or designating a separate area within a multi-bed room.
It's essential to restrict the client's movement within the healthcare facility and limit visitors to essential personnel only.
Choice C rationale:
Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus; however, it is not the most immediate priority in this situation.
The priority is to prevent further transmission by isolating the client.
Choice D rationale:
Counseling family members to monitor for symptoms is important, but it is not the most immediate priority in this situation. The priority is to prevent transmission by isolating the client.
Correct Answer is D
Explanation
Choice A rationale:
Tiotropium is a long-acting bronchodilator, not a rescue inhaler for sudden shortness of breath.
It takes several hours to reach its full effect and is not designed to provide immediate relief during acute symptoms.
Using tiotropium for sudden shortness of breath could delay the use of a more appropriate rescue medication, potentially worsening the situation.
Choice B rationale:
While tiotropium can help reduce mucus production and make secretions easier to clear, this is not its primary mechanism of action.
The client's statement focuses on a potential side effect rather than demonstrating a clear understanding of the medication's intended purpose.
Choice C rationale:
The frequency of inhaler use depends on the specific medications prescribed. Some inhalers are used daily, while others are used only as needed for symptoms.
It's essential to follow the healthcare provider's instructions for each inhaler to ensure proper use and avoid potential drug interactions.
Choice D rationale:
This statement correctly reflects the appropriate use of tiotropium.
It's typically taken once daily via a handihaler device to maintain open airways and prevent COPD symptoms. Regular daily use is crucial for optimal effectiveness.
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