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A nurse on a step-down unit is admitting a client.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again
Nurses' Notes
Day 3, 1350:
Client transferred to step-down unit from ICU for continued care following a myocardial infarction (MI) 2 days ago. Oriented to room. Client reports a productive cough, States they are short of breathand that ambulating to the bathroom has resulted in chest pain. Reports pain as 3 on a scale of 0 to 10. Client appears anxious and reports a fear of dying.

Oriented to room.

Client reports a productive cough

States they are short of breathand that ambulating to the bathroom has resulted in chest pain.

Reports pain as 3 on a scale of 0 to 10.

Client appears anxious and reports a fear of dying.

Answer and Explanation

The Correct Answer is ["B","C","E"]

Rationale for Correct Findings:

Productive cough: In a client with COPD and recent MI, this may signal infection or fluid overload, especially if paired with fever, dyspnea, and hypoxia. Immediate assessment is needed to rule out pneumonia or heart failure.
Shortness of breath and chest pain with ambulation: This raises concern for myocardial ischemia, reinfarction, or worsening heart function. Chest pain with minimal exertion post-MI demands prompt evaluation and possible ECG and oxygen therapy.
Anxiety and fear of dying: Sudden intense fear may indicate worsening hypoxia, cardiac distress, or even be a prodrome to another MI. It should not be dismissed as purely psychological, especially in the context of other concerning symptoms.

Rationale for Incorrect Findings:

Pain rated 3/10: A mild pain score suggests the discomfort is currently manageable. While chest pain after MI is always important, this level does not in itself indicate an emergency unless it worsens or is unrelieved.
Oriented to room: Being alert and oriented indicates preserved cognition and neurologic stability. No immediate follow-up is needed based on this observation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Rationale:

Bloody stools: Bloody stools are not a typical finding in either acute pancreatitis or peritonitis. They are more commonly associated with lower GI pathologies such as diverticulosis, hemorrhoids, or inflammatory bowel disease. Their absence here does not support either condition.
Hyperbilirubinemia: Hyperbilirubinemia (total bilirubin 3.7 mg/dL) may occur with pancreatitis, especially if there is biliary obstruction due to inflammation or gallstones. Obstructed bile flow leads to accumulation of bilirubin, causing jaundice as seen in this client’s yellow sclera and palate.
Elevated WBC count: Leukocytosis (WBC 18,000/mm³) is a systemic inflammatory response commonly seen in both acute pancreatitis and peritonitis. In pancreatitis, this reflects the inflammatory process of autodigestion of the pancreas. In peritonitis, it reflects infection and inflammation of the peritoneal cavity.
Abdominal pain: Severe abdominal and epigastric pain radiating to the back is classic for acute pancreatitis. Peritonitis can also cause diffuse abdominal pain with guarding and rigidity, particularly when the peritoneum becomes inflamed. The pain in peritonitis often worsens with movement, while pancreatitis pain may worsen with eating or lying flat.

A. "Avoid high-fiber foods while taking this medication." B. "Apply the patch to your forearm." C. "Avoid hot tubs while wearing the patch." D. "Remove the patch for 8 hours every day to reduce the risk of tolerance"

Correct Answer is C

Explanation

Rationale:

A. "Avoid high-fiber foods while taking this medication." High-fiber foods are encouraged when taking opioids like fentanyl due to the common side effect of constipation. Dietary fiber supports bowel function and should not be avoided.

B. "Apply the patch to your forearm." The patch should be applied to a flat, non-irritated area with minimal hair, such as the chest, back, or upper arm. The forearm is not the preferred site due to its mobility and smaller surface area.

C. "Avoid hot tubs while wearing the patch." Heat increases the absorption rate of transdermal fentanyl, potentially leading to overdose. Clients should avoid hot tubs, heating pads, or prolonged exposure to direct sunlight while wearing the patch.

D. "Remove the patch for 8 hours every day to reduce the risk of tolerance." Fentanyl patches are designed to provide continuous pain control and should not be removed intermittently. Removing the patch disrupts pain management and does not prevent tolerance, which is managed by medical adjustment if necessary.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg/hr transdermal patch. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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