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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.

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Free Nursing Study Resources

Correct Answer is ["B","C","E","F","H"]

Explanation

Rationale:

A. Initiate contact precautions: No signs of infection or communicable disease are present, so contact precautions are unnecessary.

B. Decrease lighting in the client’s room: The client is restless and later becomes lethargic, suggesting neurological irritability or worsening preeclampsia. Reducing environmental stimuli like lighting can help minimize seizures and agitation.

C. Check urinary output: The client’s urine output decreased to 20 mL in one hour, which is concerning for renal impairment often seen in severe preeclampsia. Monitoring output closely helps detect worsening kidney function and fluid balance.

D. Prepare for amniocentesis: There is no indication for amniocentesis in this clinical scenario related to preeclampsia or maternal condition.

E. Encourage bed rest: Bed rest in the side-lying position improves uteroplacental perfusion and helps control blood pressure, reducing the risk of complications from preeclampsia.

F. Monitor blood pressure: Blood pressure is elevated and critical to assess frequently to evaluate disease progression and prevent hypertensive emergencies or seizures.

G. Apply internal fetal monitor: The client has no contractions and a stable external fetal heart rate. Internal monitoring is invasive and reserved for active labor or when external monitoring is insufficient.

H. Assess DTR: The shift from hyperreflexia (3+) to hyporeflexia (1+) may indicate worsening neurological status or magnesium sulfate toxicity if administered. Continuous monitoring is essential.

A. Ketorolac B. Acetaminophen C. ibuprofen D. Aspirin

Correct Answer is B

Explanation

Rationale:

A. Ketorolac: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation and increase the risk of bleeding, especially in clients with a history of peptic ulcer disease. It should be avoided in this population.

B. Acetaminophen: Acetaminophen is the safest option for relieving headache in clients with a history of peptic ulcers because it lacks the gastrointestinal side effects associated with NSAIDs. It provides effective pain relief without increasing ulcer risk.

C. Ibuprofen: Ibuprofen, another NSAID, also carries a high risk of gastric irritation and peptic ulcer exacerbation. Chronic or even short-term use can worsen ulcers and lead to GI bleeding.

D. Aspirin: Aspirin has strong antiplatelet effects and is highly ulcerogenic. It increases the risk of gastric mucosal damage and should be avoided in clients with known peptic ulcer disease.

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Naxlex Comprehensive Predictor Exams

The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

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