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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 A

Explanation

A. Watery diarrhea is a potential sign of Clostridium difficile (C. diff) infection, a serious and common complication associated with antibiotics like linezolid.

B. Nausea and headache are side effects but are less urgent than symptoms suggesting C. diff.

C. Increased fatigue is non-specific and may be related to the infection or the medication, but it is not as immediately concerning as diarrhea.

D. Yellow-tinged sputum is typical of pneumonia and does not indicate an urgent issue related to linezolid therapy.

A. Instruct the client in the use of muscle strengthening exercises. B. Teach the need for dietary and supplemental vitamin D3. C. Encourage progressive active range of motion. D. Explain the need for skin exposure to sunlight without sunscreen.

Correct Answer is B

Explanation

A. Muscle strengthening exercises may be appropriate, but vitamin D3 is a more immediate concern for addressing bone and muscle symptoms.

B. Clients with extensive burns may have vitamin D deficiencies due to changes in metabolism, diet, or lack of sunlight exposure. Vitamin D3 is essential for calcium absorption and bone health, which is why this client’s symptoms of bone pain and muscle weakness suggest a need for supplementation.

C. Progressive range of motion exercises are beneficial for mobility but should not be prioritized over addressing nutritional deficiencies.

D. Skin exposure to sunlight without sunscreen is not recommended for this client due to their burn history and potential for further skin damage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is A

Explanation

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

Correct Answer is B

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?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

A client who fell and broke a wrist is admitted for 24 hour observation after emergency orthopedic surgery. The healthcare provider prescribes discharge in the morning. Which finding(s) should the nurse use to evaluate the client's status for discharge from the hospital? Select all that apply.

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Exhibits New data is reviewed. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. This client is exhibiting signs of dropdown. The nurse is a mandated reporter and therefore must report the elder mistreatment todropdown.

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.