Try Naxlex NCLEX-RN (Free-Trial)

The nurse is continuing to assist in the care of the client.
Exhibits
For each data collection finding, click to specify if the finding on postoperative day 1 is consistent with hypovolemic shock or pulmonary embolism. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

A.

Heart rate

B.

Respiratory effort

C.

Pain

D.

Blood pressure

E.

Mentation

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Heart rate
•    Hypovolemic Shock
o    The elevated heart rate of 104/min is consistent with hypovolemic shock, where the body compensates for reduced blood volume by increasing heart rate to maintain cardiac output and perfusion.
•    Pulmonary Embolism
o    An increased heart rate can also occur with pulmonary embolism as the body responds to decreased oxygenation and impaired cardiac function.
Respiratory effort
•    Hypovolemic Shock
o    Increased respiratory rate of 24/min may be a compensatory mechanism in hypovolemic shock to enhance oxygen delivery to tissues despite reduced blood volume.
•    Pulmonary Embolism
o    Elevated respiratory rate can also be seen in pulmonary embolism due to impaired gas exchange and increased respiratory effort to compensate for decreased oxygen levels.
Pain
•    Pulmonary Embolism
o    Pain, particularly pleuritic chest pain, is a common symptom of pulmonary embolism and could be indicative of embolic obstruction in the pulmonary circulation.
Blood pressure
•    Hypovolemic Shock
o    The drop in blood pressure to 88/54 mm Hg is consistent with hypovolemic shock, where reduced blood volume leads to decreased perfusion and hypotension.
Mentation
•    Hypovolemic Shock
o    Altered mentation, such as restlessness or agitation, can be a sign of hypovolemic shock as decreased perfusion affects brain function and consciousness.
•    Pulmonary Embolism
o    Changes in mentation can also occur in pulmonary embolism due to hypoxemia or decreased perfusion to the brain.


 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

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

Explanation

1. Bumetanide 1 mg IV stat: The client’s vital signs show hypotension (blood pressure 88/54 mm Hg) and tachycardia (heart rate 104/min). The skin is cool and moist, and capillary refill is delayed, suggesting possible fluid overload or heart failure. Bumetanide is a potent diuretic used to address fluid overload and reduce the heart's workload.

2. Packed red blood cells: The client’s urine output is low (110 mL over 6 hours), which, combined with signs of hypotension and tachycardia, may indicate significant blood loss or anemia. Administering packed red blood cells can help correct anemia and improve blood volume.

Correct Answer is B

Explanation

A. Close the doors to the room and to the bathroom: This helps to contain the smoke but does not address the immediate danger of the smoke.
B. Assist the client to a nearby common area: This is correct as ensuring the safety of the client is the top priority. The client should be moved to a safer location away from the smoke.
C. Activate the fire alarm system: This is important for alerting others to the fire but does not directly address the immediate danger to the client.
D. Use a fire extinguisher at the source of the smoke: This can be done after ensuring the client's safety, as the primary concern is to remove the client from potential harm.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register