A patient on prolonged bedrest following a pelvic fracture becomes dyspneic and confused. Pulse = 135 beats/minute, blood pressure = 90/50 mmHg, respirations = 36/minute, Oxygen saturation starts dropping rapidly. Which of the following conditions should the nurse prepare to treat for this patient?
Anxiety attack
Pneumonia
Pulmonary embolism
Asthma exacerbation
The Correct Answer is C
A. While anxiety can cause rapid breathing and confusion, the patient's clinical presentation (dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation) is more consistent with a serious physical condition, such as a pulmonary embolism, rather than an anxiety attack.
B. Pneumonia could cause dyspnea and confusion, but the rapid onset of symptoms, along with the patient's history of prolonged bed rest and risk factors, suggests a pulmonary embolism rather than pneumonia.
C. Pulmonary embolism (PE) is a life-threatening condition that can occur in patients on prolonged bedrest, especially after a pelvic fracture. The patient’s symptoms of dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation are classic signs of PE. This requires immediate intervention, including anticoagulation and possibly thrombolytic therapy.
D. Asthma exacerbation typically presents with wheezing and difficulty breathing, but it would not typically cause the severe hypotension, confusion, and rapid oxygen desaturation seen in this patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While ensuring that a client with an inguinal hernia voids before discharge is important, it does not warrant immediate intervention unless there are signs of urinary retention or other complications.
B. Refusing to deep breathe after an open cholecystectomy can increase the risk of postoperative complications like atelectasis, but it does not require immediate intervention unless there are signs of respiratory distress or infection.
C. Pain on inspiration in a client with deep vein thrombosis (DVT) is a potential sign of pulmonary embolism (PE), a life-threatening complication. Immediate assessment and intervention are critical to prevent further deterioration.
D. Refusing to turn for three hours increases the risk of pressure injuries, but this is not as urgent as the potential for a pulmonary embolism. The nurse should address this issue promptly but not before assessing the client with possible PE.
Correct Answer is C
Explanation
A. Metabolic alkalosis is not typically associated with COPD. This condition is more commonly seen in situations involving excessive vomiting, diuretic use, or certain metabolic disorders.
B. Respiratory alkalosis is not expected in COPD. In COPD, the patient often retains carbon dioxide due to impaired gas exchange, leading to respiratory acidosis rather than alkalosis.
C. Respiratory acidosis is the most common acid-base imbalance in COPD. Due to the inability to effectively exhale carbon dioxide, patients with COPD often develop hypercapnia (elevated CO2 levels), leading to respiratory acidosis. This is particularly common during exacerbations when the patient is short of breath and unable to clear CO2 adequately.
D. Metabolic acidosis is not typically associated with COPD. While it can occur in certain conditions like renal failure or diabetic ketoacidosis, it is not a primary concern in COPD exacerbations. Respiratory acidosis is the more likely finding.
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