The nurse cares for a client who sustained a femur fracture twelve hours ago.
Client reports shortness of breath and stated, 'something is not right.' The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air.

Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called.

he client is demonstrating signs and symptoms of ?

pulmonary embolism

myocardial infarction

fat embolism syndrome

compartment syndrome

Answer and Explanation

The Correct Answer is C

Choice A rationale: Pulmonary embolism would cause chest pain, dyspnea, and hemoptysis, but not petechiae or neurological changes.

Choice B rationale: While chest pain might be associated with myocardial infarction, the combination of symptoms aligns more with a pulmonary embolism.

Choice C rationale: Fat embolism syndrome occurs when fat globules from the bone marrow enter the bloodstream and travel to the lungs, brain, or other organs. This can

cause respiratory distress, neurological impairment, petechiae (reddish-purple spots on the skin), and cardiac dysfunction.

Choice D rationale: Compartment syndrome doesn't typically manifest with respiratory symptoms or reddish-purple spots.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale: After visual inspection, the next step typically involves auscultation, which allows the nurse to listen for bowel sounds and gather information about

gastrointestinal function.

Choice B rationale: Percussion involves tapping the abdomen to assess density or abnormal masses but usually follows auscultation.

Choice C rationale: Palpation, both light and deep, follows percussion in the sequence of an abdominal examination.

Choice D rationale: Similar to light palpation, deep palpation follows auscultation and percussion in the sequence of an abdominal examination.

A. A/V fistula assessment B. Blood pressure C. Pulse D. Anuria E. Oxygen saturation F. Temperature G. Neurological assessment

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

Explanation

Choice A rationale: A/V fistula assessment is not concerning because a positive bruit and thrill indicate adequate blood flow through the fistula. A dry dressing with scant amount of blood is expected after hemodialysis.

Choice B rationale: The client's low blood pressure could indicate hypotension, which can be critical, especially after hemodialysis. It may contribute to the client's reported dizziness and fatigue.

Choice C rationale: The client’s pulse is irregular which may indicate cardiac arrhythmia. Choice D rationale: Anuria, the absence of urine output, is a significant concern. It could indicate kidney dysfunction or inadequate clearance of waste products, which may have implications following hemodialysis.

Choice E rationale: Oxygen saturation at 92% is relatively low. While the client is alert and oriented, a low oxygen saturation level may indicate potential respiratory compromise or inadequate oxygenation.

Choice F rationale: Temperature is not concerning because it is within normal range.

Choice G rationale: Neurological assessment is not concerning because the client is alert and oriented. The dizziness is likely related to the hypotension and will resolve once the blood pressure is stabilized.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination?

Correct Answer is A

Explanation

The nurse is caring for a 67-year-old client in the medical-surgical unit following hemodialysis. The nurse reviews the nursing note, vital signs, assessment, and medical history Which clinical data is most concerning to the nurse? Select all that apply

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

Explanation

The RN is serving as preceptor to a new graduate nurse who has recently passed the RN licensure (NCLEX®) examination. The new nurse has only been on the unit for 2 days. Which patient should be assigned to the new graduate nurse?

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer?

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?

A nurse is developing a plan of care for a client with a new diagnosis of Graves' disease. Which of the following interventions does the nurse include in the plan of care?

The medical reports of a client who suffered an accident show injuries at the sixth thoracic vertebra, lack of normal sympathetic outflow, bradycardia and low blood pressure. Which condition does the nurse suspect in the client?

The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

A patient with gonorrhea is treated with a single IM dose of ceftriaxone and is given a prescription for azithromycin (Zithromax) 1000 mg 1 dose. What rationale should the nurse provide to the patient for this combination?

A 25-year-old female presents with amenorrhea and hirsutism and is diagnosed with polycystic ovary syndrome (PCOS). Lab testing will most likely reveal: