The nurse is caring for a client.
Complete the following sentence by using the lists of options.
The client is most likely experiencing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "What part of this assignment makes you upset?": This response encourages open communication, allowing the staff nurse to express specific concerns. It demonstrates active listening, validation of feelings, and promotes problem-solving in a professional and supportive manner.
B. "Let's discuss how this affects your performance improvement plan.": This response shifts the focus to evaluation or discipline rather than addressing the immediate concern. It may create defensiveness and does not validate the nurse’s feelings or allow for discussion of the assignment issue.
C. "Why are you talking to me instead of the charge nurse?": This response is dismissive and may discourage the staff nurse from voicing concerns in the future. It does not address the fairness of the assignment or explore potential solutions.
D. "You are not the only one with a heavy assignment today.": Comparing workloads minimizes the nurse’s concerns and can be perceived as unsupportive. It does not facilitate problem-solving or acknowledge the staff nurse’s feelings about the assignment.
Correct Answer is ["B","D","F"]
Explanation
A. Place the client in a supine position: The supine position can worsen dyspnea by limiting diaphragmatic movement and decreasing lung expansion. Clients with respiratory distress should be positioned upright or semi-Fowler’s to facilitate breathing.
B. Instruct the client to perform diaphragmatic breathing: Diaphragmatic breathing helps improve oxygenation and ventilation by promoting deeper, more efficient breaths. It also reduces accessory muscle use and can decrease anxiety associated with shortness of breath.
C. Increase oxygen flow rate to 4 L/min: Oxygen should be titrated to maintain target saturation (usually 92–94% for COPD risk patients). The client’s current oxygen saturation is 92% on 2 L/min, so increasing the flow is unnecessary at this time.
D. Assess the client's breath sounds: Ongoing assessment of breath sounds is essential to monitor for changes such as wheezing, crackles, or diminished air entry, which guide interventions and evaluate response to therapy.
E. Restrict the client's fluid intake: Fluid restriction is not indicated in this client’s current presentation. Adequate hydration helps thin secretions, making coughing and airway clearance more effective.
F. Perform chest percussion and vibration: Chest physiotherapy techniques like percussion and vibration can help loosen and mobilize secretions, improving airway clearance in clients with productive cough and retained secretions.
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