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 D
Explanation
A. Make referrals to support services: Referrals to social, medical, or mental health support are part of the response and recovery phases, focusing on addressing ongoing client needs after the disaster occurs, rather than planning.
B. Coordinate care in shelters: Coordinating care in shelters is an activity performed during the response phase, when the disaster has already occurred and immediate client needs must be addressed. It is not part of pre-event planning.
C. Triage injured individuals: Triage occurs during the response phase to prioritize treatment based on injury severity. This action is reactive to actual casualties and is not part of the planning phase.
D. Participate in practice drills: Engaging in disaster preparedness drills is a key component of the planning phase. Drills help identify gaps in emergency protocols, improve staff readiness, and ensure effective coordination during an actual mass casualty incident.
Correct Answer is A
Explanation
A. Ask the client to rate their pain on a scale of 0 to 10: Pain assessment is the first step in managing pain effectively. Using a standardized pain scale helps determine the severity, effectiveness of the previous dose, and guides subsequent interventions or medication adjustments.
B. Request a prescription for an opioid pain medication for the client: While opioids may be appropriate for breakthrough pain, the nurse must first assess the current pain level and response to prior medication before requesting additional prescriptions. Immediate escalation is premature without assessment.
C. Report this client finding to the provider: Reporting is important if pain persists despite interventions, but initial assessment and documentation of pain severity should precede notifying the provider to provide accurate information.
D. Administer an additional dose of ibuprofen to the client: Administering another dose without verifying timing, maximum daily dosage, or assessing pain response could risk overdose or toxicity. Pain assessment must guide safe medication administration.
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