The nurse is caring for a client.
Highlight the findings that require immediate follow-up by the nurse
Client reports sudden onset of dyspnea and chest discomfort. Client transferred back to bed. Client is awake and orientated x4. Client states, "I just feel like something is really wrong."
Client is tachypneic and appears in distress. Crackles heard in bilateral lungs. S3 and S4 heart sounds noted. Bilateral pedal pulses are +1. Surgical site is dressed, dry, and intact.
Temperature 38.9° C (102° F)
Heart rate 112/min
Respiratory rate 34/min
Blood pressure 144/72 mm Hg
Oxygen saturation 92% on 2 L via nasal cannula
Client reports sudden onset of dyspnea and chest discomfort
Client is awake and orientated x4
Client is tachypneic and appears in distress
Crackles heard in bilateral lungs.
S3 and S4 heart sounds noted.
Surgical site is dressed, dry, and intact
Temperature 38.9° C (102° F)
Heart rate 112/min
Respiratory rate 34/min
The Correct Answer is ["A","C","D","E","G","H","I"]
Rationale for correct choices
• Sudden onset of dyspnea and chest discomfort: These symptoms may indicate acute cardiopulmonary compromise such as pulmonary embolism, acute heart failure, or infection. Sudden dyspnea in a post-op orthopedic client requires immediate assessment and intervention to prevent deterioration.
• Tachypnea and appearance of distress: Rapid, labored breathing indicates the client is struggling to maintain adequate oxygenation and may signal hypoxemia or respiratory failure. Immediate follow-up is necessary to prevent further compromise.
• Crackles heard in bilateral lungs: Bilateral crackles suggest fluid accumulation in the alveoli, possibly from pulmonary edema or early pneumonia. This finding correlates with respiratory distress and requires prompt evaluation.
• S3 and S4 heart sounds noted: Extra heart sounds can indicate left ventricular dysfunction or volume overload, suggesting acute heart failure. Timely assessment is critical to prevent worsening cardiac output and pulmonary congestion.
• Temperature 38.9° C (102° F): Fever indicates possible infection, which in a post-operative patient could suggest pneumonia, surgical site infection, or sepsis. Early recognition and treatment are essential.
• Heart rate 112/min: Tachycardia may be a compensatory response to hypoxia, fever, or fluid overload. Persistent elevation increases cardiac workload and risk of decompensation.
• Respiratory rate 34/min: A significantly elevated respiratory rate confirms respiratory distress and inadequate oxygenation, warranting immediate intervention such as supplemental oxygen adjustment or further diagnostics.
Rationale for incorrect choices
• Client is awake and oriented x4: The client’s alertness and orientation indicate that cerebral perfusion and cognitive function are intact at this time. While this is important to note, it does not indicate acute cardiopulmonary compromise or a life-threatening event, so it does not require immediate follow-up.
• Surgical site is dressed, dry, and intact: The dressing being clean, dry, and intact indicates there is currently no active bleeding or wound complication. While ongoing monitoring is important post-operatively, this finding does not necessitate urgent intervention compared with the client’s acute respiratory and cardiovascular symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Rationale for correct choices
• Fatigue lasting longer than 4 months: Persistent fatigue can indicate an underlying chronic condition, autoimmune disorder, or neurological disease. Because it has lasted longer than several months, it warrants further assessment to rule out systemic or neurological causes. Chronic fatigue can significantly impair quality of life and functional capacity.
• Struggling to remember things and feeling depressed: Cognitive changes and mood disturbances may reflect neurological involvement, medication side effects, or comorbid depression. Memory issues combined with fatigue and mood changes require follow-up to assess for conditions affecting the central nervous system or systemic illness.
• Intermittent hand tremors: Hand tremors can indicate neurological disorders such as myasthenia gravis, Parkinsonism, or other neuromuscular conditions. Intermittent tremors, especially alongside muscle weakness and visual disturbances, warrant evaluation to determine the underlying etiology.
• Sudden episodes of leg weakness causing loss of balance and gait changes: Episodes of acute limb weakness with balance problems indicate potential neuromuscular dysfunction or demyelinating disease. These transient episodes impair safety and functional mobility, requiring further neurological evaluation to prevent injury.
• Intermittent muscle spasms: Muscle spasms are concerning when combined with other neuromuscular symptoms. They may indicate electrolyte imbalance, neuromuscular junction disorders, or early signs of autoimmune or neurological disease. Tracking frequency and triggers helps guide diagnosis.
• Occasional double vision: Intermittent diplopia may indicate cranial nerve involvement or neuromuscular junction pathology, such as myasthenia gravis. Even if infrequent, visual disturbances in combination with muscle weakness are red flags requiring neurological assessment.
• Genitourinary spasms: Spasms in the urinary tract may reflect neurological involvement or early autonomic dysfunction. Although infrequent, these symptoms can signal progression of a neuromuscular condition affecting bladder control and require follow-up to prevent complications.
Rationale for Incorrect findings
• Vital signs within normal limits: Temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation are all within normal ranges and do not currently indicate acute illness. No immediate intervention is required based on these values.
• Last bowel movement 1 day ago: Having a bowel movement within the last 24 hours is normal and does not indicate constipation or gastrointestinal dysfunction. No immediate follow-up is needed for bowel habits at this time.
Correct Answer is A
Explanation
A. Progestin oral contraceptive: Progestin-only oral contraceptives (often called the “mini-pill”) are safe to use immediately postpartum for breastfeeding clients because they do not affect milk production. They provide effective contraception without the risks associated with estrogen-containing methods.
B. Vaginal etonogestrel/ethinyl estradiol contraceptive ring: Combination estrogen-progestin contraceptives, such as the vaginal ring, are generally not recommended immediately postpartum for breastfeeding clients because estrogen can reduce milk supply and may increase the risk of thromboembolism.
C. Transdermal estrogen/progesterone patch: Similar to other estrogen-containing methods, the transdermal patch is not recommended immediately postpartum for breastfeeding clients due to potential interference with lactation and increased thromboembolism risk.
D. Injectable synthetic progestin: Injectable progestin (e.g., depot medroxyprogesterone acetate) is safe for breastfeeding, but it is not ideal for immediate postpartum use if the client wishes for rapid return to fertility later, since its effects can last for several months. It may also have delayed effects on bone density with long-term use.
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