A nurse is caring for a client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
due to
.
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis.
Rationale:
The client has a progressively enlarging, reddened area on the left calf with increasing calf circumference (40 cm → 42 cm in 24 hours), suggesting a developing deep vein thrombosis (DVT). A history of recent prolonged immobility (8-hour car trip) increases the risk of venous stasis, a major factor in DVT formation.
Low blood pressure (106/55 mm Hg) and elevated temperature (38°C/100.4°F) may indicate a systemic inflammatory response.
DVT can lead to pulmonary embolism (PE) if a clot dislodges and travels to the lungs.
Symptoms of PE include sudden dyspnea, chest pain, tachycardia, and hypoxia.
Early identification of DVT is crucial to prevent life-threatening PE.
Incorrect Options:
Lead poisoning → Home environment: No exposure to lead-based hazards is mentioned.
Pneumonia → Breath sounds: The client has clear breath sounds, ruling out pneumonia.
Atherosclerosis → Blood pressure: The client’s BP is not severely elevated, and no risk factors for atherosclerosis are noted.
Constipation → Diet: The client eats a high-fiber diet and drinks 2,000 mL of fluid daily, reducing constipation risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Oxygenation:
The client's SaO₂ is 90% on 2 L/min via nasal cannula, which indicates impaired oxygenation. The client is experiencing rapid, labored breathing, suggesting respiratory distress. Cyanosis (bluish tint to extremities) and mottled skin indicate poor oxygen delivery to tissues. Addressing oxygenation first is critical to prevent worsening hypoxia and potential respiratory failure.
Blood Pressure:
The client has hypotension (74/50 mm Hg), likely due to malnutrition, dehydration, and inadequate caloric intake. Weak pulses, cold skin, and poor turgor suggest circulatory compromise that needs intervention. After stabilizing oxygenation, the nurse should address the low blood pressure to prevent shock.
Correct Answer is []
Explanation
The client presents with chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort, which are classic signs of an acute MI.
ST-elevation on ECG and elevated troponin levels confirm myocardial infarction.
Actions to Take:
Administer Oxygen via nasal cannula 2 L/min: The client’s oxygen saturation is 88%, which is below the normal range. Supplemental oxygen helps improve myocardial oxygenation.
Request a prescription for aspirin 325 mg: Aspirin is a first-line treatment for MI as it prevents further platelet aggregation and reduces the risk of clot progression.
Parameters to Monitor:
Vital signs: Blood pressure, heart rate, and respiratory rate should be closely monitored to assess cardiovascular stability.
Electrocardiogram (ECG) rhythm: Continuous ECG monitoring is essential to detect arrhythmias, ischemic changes, or worsening ST elevation that may indicate ongoing myocardial injury.
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