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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Notifying the client's family may be appropriate after assessing the client and identifying the cause of the confusion. However, it is not the first action, as the priority is to determine if the confusion is due to a medical condition requiring immediate attention.

B. Instructing the client to return to their room addresses the wandering behavior but does not address the underlying cause of the new onset confusion. Without further assessment, this action may delay necessary interventions.

C. Asking the UAP to push fluids assumes that dehydration is the cause of the confusion without evidence. While encouraging hydration may be beneficial later, it is essential first to assess for other potential causes, such as infection or hypoxia.

D. Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection (e.g., pneumonia or urinary tract infection) or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.

A. Continuous bubbling within the water seal chamber B. Fluctuation of the fluid level within the water seal chamber C. Absence of fluid in the drainage tubing D. Equal amounts of fluid drainage in each collection chamber

Correct Answer is B

Explanation

A. Continuous bubbling within the water seal chamber indicates an air leak in the system, which is not a sign of proper chest tube functioning. The nurse should investigate and address any air leaks promptly.

B. Fluctuation of the fluid level within the water seal chamber, also known as tidaling, indicates that the chest tube is functioning properly. Tidaling reflects changes in intrapleural pressure during respiration and confirms that the system is intact.

C. Absence of fluid in the drainage tubing is not an indicator of proper functioning. Depending on the client’s condition, there may or may not be fluid in the tubing. However, the system should always be assessed for patency and appropriate drainage.

D. Equal amounts of fluid drainage in each collection chamber are not expected or required. The amount of drainage depends on the client’s condition and does not indicate the functionality of the chest tube system.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

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