A nurse is teaching a client who has a pelvic fracture about the manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?
Hypertension
Swollen calf
Tachypnea
Bradycardia
The Correct Answer is C
Choice A reason:
Hypertension is not typically an early manifestation of fat embolism syndrome (FES). FES is more commonly associated with hypoxemia, which can lead to hypotension rather than hypertension².
Choice B reason:
While a swollen calf may indicate deep vein thrombosis, it is not an early sign of FES. FES primarily affects the lungs and neurological systems early on, rather than causing localized swelling such as in a calf².
Choice C reason:
Tachypnea, or rapid breathing, is indeed an early sign of FES. This symptom usually develops before others and is due to the fat globules causing respiratory distress by blocking the pulmonary microcirculation²³⁴.
Choice D reason:
Bradycardia, or a slower than normal heart rate, is not an early sign of FES. Instead, patients may experience tachycardia as a response to hypoxemia and respiratory distress².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Monitor the client for hypoglycemia
When a nurse administers an incorrect insulin dose, the immediate concern is the risk of hypoglycemia, especially since the insulin dose given was for a higher blood glucose level than the actual reading. Hypoglycemia can occur when blood glucose levels drop below 70 mg/dL. Symptoms of hypoglycemia include shakiness, sweating, confusion, and in severe cases, loss of consciousness. Monitoring the client for hypoglycemia allows the nurse to detect and treat it promptly, ensuring the client’s safety.
Choice B: Complete an incident report
While completing an incident report is important for documenting the medication error and preventing future occurrences, it is not the immediate priority. The nurse’s first responsibility is to ensure the client’s safety by addressing the potential hypoglycemia. Once the client’s condition is stable, the nurse can then complete the incident report.
Choice C: Give the client 15 to 20 g of carbohydrate
Administering 15 to 20 grams of carbohydrate is a treatment for hypoglycemia. However, this action should only be taken if the client is actually experiencing hypoglycemia. The nurse should first monitor the client’s blood glucose levels to confirm hypoglycemia before administering carbohydrates.
Choice D: Notify the nurse manager
Notifying the nurse manager is important for accountability and to ensure that appropriate follow-up actions are taken. However, it is not the immediate priority. The nurse should first monitor the client for hypoglycemia and address any immediate health concerns before notifying the nurse manager.
Correct Answer is C
Explanation
Choice A reason:
Hay fever allergy, also known as allergic rhinitis, is primarily associated with the action of Immunoglobulin E (IgE) antibodies and not directly with T-cells. T-cells can contribute to the regulation of the immune response in allergies, but IgE is the main immunoglobulin involved in the typical symptoms of hay fever.
Choice B reason:
Anaphylaxis is a severe, potentially life-threatening allergic reaction that involves the release of large amounts of histamine and other chemicals from mast cells and basophils, often triggered by IgE antibodies. While T-cells can play a role in the sensitization phase of allergy, anaphylaxis itself is not directly caused by T-cells.
Choice C reason:
Transplant rejection is a process in which T-cells play a central role. When a transplant recipient's immune system recognizes the donated organ as foreign, T-cells can mediate the rejection by attacking the transplanted tissue, leading to its failure.
Choice D reason:
Bacterial phagocytosis is primarily the function of phagocytes like neutrophils and macrophages. T-cells are involved in the adaptive immune response and can activate phagocytes, but they do not directly perform phagocytosis.
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