The nurse cares for a client who sustained a femur fracture twelve hours ago.
Client reports shortness of breath and stated, 'something is not right.' The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air.

Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called.

he client is demonstrating signs and symptoms of ?

pulmonary embolism

myocardial infarction

fat embolism syndrome

compartment syndrome

Answer and Explanation

The Correct Answer is C

Choice A rationale: Pulmonary embolism would cause chest pain, dyspnea, and hemoptysis, but not petechiae or neurological changes.

Choice B rationale: While chest pain might be associated with myocardial infarction, the combination of symptoms aligns more with a pulmonary embolism.

Choice C rationale: Fat embolism syndrome occurs when fat globules from the bone marrow enter the bloodstream and travel to the lungs, brain, or other organs. This can

cause respiratory distress, neurological impairment, petechiae (reddish-purple spots on the skin), and cardiac dysfunction.

Choice D rationale: Compartment syndrome doesn't typically manifest with respiratory symptoms or reddish-purple spots.

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Correct Answer is D

Explanation

Choice A rationale: This is not the accurate amount of fluid intake by the patient.

Choice B rationale: This is less than the total fluid intake by the patient.

Choice C rationale: This is less than the total fluid intake by the patient.

Choice D rationale: This is correct.( This is the sum of the intravenous fluid, the water, and the chicken broth, converted to milliliters: 650 + (6 x 30) + (8 x 30) = 1070.)

A. The skin under the appliance looks red briefly after removing the appliance. B. The stoma color is a deep red-purple. C. An ascending colostomy delivers liquid feces. D. The stoma extends 1/2 inch above the abdomen.

Correct Answer is B

Explanation

Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.

Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.

Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.

Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

Correct Answer is B

Explanation

The nurse is reviewing the record of a female client with Crohn's disease. Which stool characteristics should the nurse expect to note documented in the client's record?

A patient received teaching about the correct procedure in a 24-hour urine collection for creatinine clearance test. Which statement by the client indicates a need for further teaching?

A 16-year-old male presents to the emergency department with right knee pain. Exhibits Complete the statement below: The client is at risk for and the nurse should ?

The RN is serving as preceptor to a new graduate nurse who has recently passed the RN licensure (NCLEX®) examination. The new nurse has only been on the unit for 2 days. Which patient should be assigned to the new graduate nurse?

The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination?

A nurse is developing a plan of care for a client with a new diagnosis of Graves' disease. Which of the following interventions does the nurse include in the plan of care?

Upon physical examination, the nurse detects abdominal tenderness, increased bowel sounds accompanied by signs of borborygmi, abdominal distension, and tympany on percussion. Which diagnostic test will confirm Crohn's disease in the client?

A 23-year-old sexually active female presents with white copious discharge and itch and is diagnosed with yeast vaginitis. This condition is caused by overgrowth of which microorganism?