The nurse is caring for a client.

Complete the following sentence by using the lists of options.

The client is most likely experiencing
_
due to
_
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Rationale for correct choices

• Pulmonary embolism: The client exhibits sudden onset of dyspnea, chest discomfort, tachypnea, hypoxemia (oxygen saturation 92% on 2 L O₂), and appears in respiratory distress, all of which are classic signs of a pulmonary embolism. Postoperative orthopedic patients, especially after hip arthroplasty, are at high risk due to immobility, venous stasis, and hypercoagulability.

• Recent surgery: The client’s recent total hip arthroplasty increases the risk of thromboembolic events. Surgical procedures, particularly major orthopedic surgeries, create a hypercoagulable state and contribute to venous stasis, which can precipitate a pulmonary embolism.

Rationale for incorrect choices

• Pneumothorax: Pneumothorax typically presents with unilateral chest pain, sudden shortness of breath, and decreased or absent breath sounds on one side. The client’s crackles are bilateral and S3/S4 heart sounds are present, which are not consistent with pneumothorax.

• Pneumonia: Although the client has fever and crackles, the sudden onset of symptoms and acute respiratory distress are more consistent with pulmonary embolism rather than pneumonia, which usually develops gradually. Additionally, the timing shortly after surgery favors a thromboembolic event over an infectious process.

• Tobacco use: The client reports no history of tobacco use, making this an irrelevant risk factor for the current acute episode.

• Activity level: While immobility can contribute to thrombus formation, the client ambulated with assistance earlier, and the more significant risk factor remains recent surgery, which directly predisposes to pulmonary embolism.

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Correct Answer is C

Explanation

A. Discuss the incident with the health care worker: While addressing the suspected impairment with the worker is important, immediate removal from the work environment takes priority to ensure patient safety and prevent potential harm. Confrontation can follow after securing a safe environment.

B. Document the findings of the incident: Documentation is essential for legal and professional accountability, but it is secondary to protecting patients from immediate risk. Recording observations does not prevent ongoing exposure to unsafe practice.

C. Remove the health care worker from the work environment: The first priority is ensuring patient safety. Suspected chemical impairment can impair judgment, coordination, and response time, creating a high risk for errors or accidents. Immediate removal prevents potential harm to clients and coworkers.

D. Place the health care worker on probation: Probation is a disciplinary measure that may follow an investigation, but it is not the first step. Immediate action must focus on safety, and probation does not address the urgent risk posed by active impairment.

A. Take this medication at the same time each day. B. Take ginger for constipation while on this medication. C. Eat foods high in vitamin K. D. Shave with disposable razors.

Correct Answer is A

Explanation

A. Take this medication at the same time each day: Consistent timing helps maintain stable anticoagulation levels and reduces the risk of under- or over-anticoagulation. Warfarin’s effectiveness and safety depend on steady dosing and adherence to a regular schedule.

B. Take ginger for constipation while on this medication: Ginger can increase the risk of bleeding when taken with warfarin due to its antiplatelet properties. Clients should avoid supplements or herbal remedies that may interact with anticoagulants unless approved by the healthcare provider.

C. Eat foods high in vitamin K: Foods high in vitamin K, such as leafy greens, can decrease the effectiveness of warfarin by promoting clotting. Clients should maintain a consistent intake rather than increasing consumption to avoid fluctuations in anticoagulation levels.

D. Shave with disposable razors: Clients on warfarin are advised to use electric razors instead of disposable or manual razors to reduce the risk of cuts and bleeding. Using disposable razors increases the likelihood of minor injuries that can lead to excessive bleeding.

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The nurse is caring for a client. Complete the following sentence by using the lists of options. The client is most likely experiencing _____ due to _____ .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager suspects a health care worker is experiencing chemical impairment. Which of the following actions should the nurse manager take first?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who is taking warfarin. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

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The nurse is caring for a client.

Complete the following sentence by using the lists of options.

The client is most likely experiencing
_
due to
_
.