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Exhibits

Click to highlight the findings that require follow up.

Neurological: Alert and oriented. Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Gastrointestinal: Within normal limits (WNL).

Genitourinary: WNL

Musculoskeletal: WNL

Pain: 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

Alert and oriented

chest pain described as pressure and tightness that is unrelieved with rest

Radial and pedal pulses 2+

Capillary refill 2 seconds

Rapid and shallow breaths

Clear breath sounds throughout bilateral lungs

7 on a 0 to 10 scale, tightness and pressure in chest

Answer and Explanation

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

Chest pain described as pressure and tightness that is unrelieved with rest: Chest pain that is described as tightness and pressure, particularly when unrelieved by rest, is a classic presentation of acute coronary syndrome (ACS), which includes conditions such as unstable angina or myocardial infarction (MI). This is a red flag symptom, as it indicates a need for immediate medical attention to rule out life-threatening conditions like MI, which can be fatal without timely intervention.

Rapid shallow breaths: Rapid and shallow breathing can be a response to acute pain, particularly in a situation involving cardiovascular stress. It may be indicative of the body's attempt to compensate for inadequate oxygenation due to cardiac ischemia, hypoxia, or anxiety.

Pain 7/10, tightness and pressure in the chest: A pain rating of 7/10 demands immediate evaluation and management, as it could indicate an evolving cardiovascular event. Moreover, tightness and pressure are specific descriptors of pain seen in ischemic heart disease, where there is reduced blood flow to the heart muscle, leading to discomfort due to oxygen deprivation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is []

Explanation

Potential condition:

TACO is a complication that can occur during or shortly after a blood transfusion, particularly in children. It happens when the volume of blood infused exceeds the circulatory system's ability to handle it, leading to fluid overload. In this case, the child is receiving 250 mL of packed red blood cells (PRBCs), and there are signs that the child may be experiencing fluid overload, such as tachycardia, hypotension, headache, and flushing. The elevated heart rate (115 beats/minute) and low blood pressure (88/44 mm Hg) after the transfusion started suggest that the child may be at risk for circulatory overload. These symptoms, combined with the increased temperature (100.9°F, 38.3°C), further support the likelihood of TACO.

Actions to Take:

Stop the blood transfusion: This is the first and most important step when transfusion-related complications, such as TACO, are suspected. Stopping the transfusion immediately helps to prevent further exacerbation of the fluid overload, which could lead to worsening respiratory distress and circulatory compromise.

Administer an antipyretic: The child has developed a fever (100.9°F), which could be a response to the transfusion. Administering an antipyretic such as acetaminophen or ibuprofen can help manage the fever, provide comfort, and prevent further complications. Fever management is important, especially in transfusion reactions, as it helps reduce the risk of complications such as febrile non-hemolytic transfusion reactions (FNHTR).

Parameters to Monitor:

Blood pressure: Monitoring the blood pressure is critical in assessing the child’s circulatory status. A low blood pressure (88/44 mm Hg), especially in the context of tachycardia, indicates that the child is experiencing hypotension, which is often associated with circulatory overload. Close monitoring of blood pressure will help guide the decision to start appropriate treatments, such as diuretics, to manage the overload.

Hematocrit: The hematocrit value provides information about the oxygen-carrying capacity of the blood. Given that the child’s hemoglobin was 6.5 g/dL (65 g/L) prior to the transfusion, it’s important to continue monitoring the hematocrit to assess the effectiveness of the PRBC transfusion. If the hematocrit remains low despite transfusion, it could indicate an ongoing issue with blood volume or oxygen delivery to tissues.

A. Encourage the use of assistive feeding devices. B. Demonstrate use of a tucked-chin position while eating. C. Assist the client to lie down and turn to the side. D. Recommend the use of supplemental liquid feedings.

Correct Answer is B

Explanation

A: Assistive feeding devices may help, but they do not directly address the risk of aspiration. Improving swallowing mechanics is more immediately beneficial.

B: The tucked-chin position helps protect the airway by improving swallowing coordination and reducing the risk of aspiration during meals. It is a simple technique that can significantly help clients with swallowing difficulties.

C: Lying down can increase the risk of aspiration by allowing food to enter the airway more easily.

D: Supplemental liquid feedings may be necessary for some ALS patients, but addressing the client’s swallowing technique during meals should take priority to prevent aspiration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

Correct Answer is B

Explanation

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