A nurse is caring for a client who is on the cardiac step-down unit.

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing
_
as evidenced by their
__

Answer and Explanation

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

Rationale for correct choices

• Stroke: The client developed new-onset atrial fibrillation with a rapid ventricular response, which significantly increases the risk for thrombus formation and subsequent embolic stroke. Atrial fibrillation after cardiac surgery can lead to stasis of blood in the atria, particularly the left atrial appendage, predisposing the client to cerebrovascular events.

• Cardiac rhythm: Monitoring cardiac rhythm is essential because changes such as atrial fibrillation, tachyarrhythmias, or pauses indicate altered hemodynamics and potential complications. The irregular, rapid atrial fibrillation observed at 1130 highlights the client’s immediate risk for embolic events. Continuous cardiac monitoring allows prompt recognition and intervention to prevent stroke

Rationale for incorrect choices

• Atelectasis: Atelectasis would present with diminished lung sounds, crackles, dyspnea, or hypoxemia. In this case, lung sounds are clear bilaterally, oxygen saturation is slightly decreased but not critically low, and the client reports no respiratory distress. These findings make atelectasis less likely.

• Cardiac tamponade: Cardiac tamponade is characterized by hypotension, jugular venous distension, muffled heart sounds, and tachycardia. Although the client has tachycardia, blood pressure is only mildly decreased, JVD is absent, and heart sounds are normal. These findings do not support cardiac tamponade at this time.

• Pneumothorax: Pneumothorax would present with diminished or absent lung sounds on the affected side, sudden dyspnea, and decreased oxygen saturation. Lung sounds are clear bilaterally, chest tubes are patent, and oxygen saturation is only slightly decreased, which is insufficient evidence for pneumothorax.

• Infection: Early postoperative infection might present with fever, redness, or drainage at surgical sites. The client’s dressings are clean, dry, and intact, with only a mild temperature elevation, which may be a normal postoperative response rather than a true infection. There is no other clinical evidence to support infection as an immediate concern.

• Chest tube assessment: Chest tube assessment is important for monitoring pneumothorax or fluid accumulation but is not related to the immediate risk of stroke. The chest tubes are patent, with tidaling present and no air leak, indicating proper function. This parameter does not reflect the client’s thromboembolic risk.

• Lung sounds: Lung sounds are clear and do not indicate respiratory compromise or atelectasis. While important for overall assessment, lung auscultation does not provide evidence of the client’s risk for stroke in the context of new atrial fibrillation.

• Heart sounds: Heart sounds are normal with no extra sounds or murmurs. While auscultation is part of cardiac assessment, the primary risk for stroke is related to the cardiac rhythm rather than auscultatory findings.

• Dressing assessment: Dressings are clean, dry, and intact, indicating no current surgical site complications. This parameter does not contribute to identifying the client’s stroke risk.

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Correct Answer is B

Explanation

A.A gastric residual volume (GRV) of 250 mL is a finding that requires monitoring but typically does not require "immediate" intervention or the cessation of feeding. Current evidence-based guidelines often suggest that feedings should not be held unless the GRV exceeds 500 mL in a single measurement or if the client shows signs of intolerance (e.g., abdominal distension, nausea). While 250 mL indicates a slight delay in gastric emptying, it is not an acute emergency compared to the risk of aspiration from supine positioning.

B.The client is lying in a supine position: The client lying in a supine position requires immediate intervention. Clients receiving enteral feedings must have the head of the bed elevated to at least 30° to 45° at all times to prevent gastric reflux and aspiration. In a post-laryngectomy client, the risk is even higher because the anatomical changes to the upper airway make it easier for regurgitated feeding to enter the trachea. The nurse must immediately raise the head of the bed to ensure the client's safety.

C. The infusion pump for administering continuous feeding is turned off: The pump being turned off interrupts nutrition delivery, which is undesirable, but it does not pose an immediate risk to the client’s safety. Correcting the pump can be done after addressing more urgent issues.

D. The enteral feeding bag and tubing are not dated: Lack of dating increases the risk of infection due to prolonged use, but this is a routine safety concern and does not require immediate intervention compared with high gastric residual volumes that pose aspiration risk.

A. Inform the client of available community resources. B. Assist the client in finding child care options. C. Agree upon short-term goals for the client. D. Ask the client about their understanding of the diagnosis.

Correct Answer is D

Explanation

A. Inform the client of available community resources: While providing information about resources is important for ongoing support, it is secondary to assessing the client’s current understanding and emotional state regarding their terminal diagnosis.

B. Assist the client in finding child care options: Child care support is a practical need but should be addressed after establishing the client’s comprehension of their condition and immediate priorities for care and planning.

C. Agree upon short-term goals for the client: Goal setting is essential for care planning, but it depends on the client’s understanding of their prognosis and needs. Establishing understanding first ensures that goals are realistic and meaningful.

D. Ask the client about their understanding of the diagnosis: Clarifying the client’s understanding is the priority because it guides all subsequent teaching, decision-making, and care planning. It ensures that interventions align with the client’s knowledge, values, and preferences at this critical stage.

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A nurse is caring for a client who is on the cardiac step-down unit. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing _____ as evidenced by their ______

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client who is on the cardiac step-down unit.

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing
_
as evidenced by their
__