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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: A breast lump that increases in size before the menstrual period might be related to hormonal changes and is not necessarily indicative of a concerning issue.
Choice B rationale: Bilateral breast nodules that are tender with palpation might be related to benign conditions or hormonal changes.
Choice C rationale: A small, mobile, rubbery breast lump could suggest a benign condition like a fibroadenoma, which might not be as concerning.
Choice D rationale: A breast nodule that is 1 cm in size, nontender, and fixed could potentially raise concerns about malignancy and requires further evaluation.
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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