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The nurse is caring for a client.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

1900:

Client reports sudden onset of dyspnea and chest discomfort. Client transferred back to bed. Client is awake and orientated x4. Client states, "I just feel like something is really wrong."

Client is tachypneic and appears in distress. Crackles heard in bilateral lungs. S3 and S4 heart sounds noted. Bilateral pedal pulses are +1. Surgical site is dressed, dry, and intact.

Vitals Signs

1900:

Temperature 38.9°C (102° F)

Heart rate 112/min

Respiratory rate 34/min

Blood pressure 144/72 mm Hg

Oxygen saturation 92% on 2 L/min via nasal cannula

Client reports sudden onset of dyspnea and chest discomfort.

Client is awake and orientated x4.

Client is tachypneic and appears in distress.

S3 and S4 heart sounds noted.

Bilateral pedal pulses are +1.

Respiratory rate 34/min

Blood pressure 144/72 mm Hg

Oxygen saturation 92% on 2 L/min via nasal cannula

Answer and Explanation

The Correct Answer is ["A","C","D","F","H"]

Rationale for Correct Answers:

Sudden onset of dyspnea and chest discomfort: Any sudden respiratory distress or chest pain post-surgery is a red flag for pulmonary embolism or myocardial infarction.
Client is tachypneic and appears in distress: Rapid breathing and physical signs of distress indicate the client is struggling to maintain adequate ventilation and oxygenation.
S3 and S4 heart sounds noted: The presence of extra heart sounds can indicate acute heart failure or ventricular strain, which may occur if the heart is struggling against a pulmonary obstruction.
Respiratory rate 34/min: This is significantly above the normal range (12–20/min) and confirms severe tachypnea.
Oxygen saturation 92% on 2 L/min via nasal cannula: Despite receiving supplemental oxygen, the saturation is below the expected 95–100%, indicating impaired gas exchange.

Rationale for Incorrect Answers:

Client is awake and orientated x4: While positive, this is a baseline neurologic expectation and does not represent an acute deterioration in this context.
Bilateral pedal pulses are +1: While slightly diminished, the fact that they are bilateral and present suggests peripheral perfusion is occurring, though this should be monitored relative to the client's baseline.
Blood pressure 144/72 mm Hg: While slightly elevated, this is relatively stable compared to the 0900 reading (142/68) and is not as immediate a priority as the respiratory distress.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Apply warm compresses to eyes (Unanticipated): This intervention has no role in managing a pituitary adenoma or increased intracranial pressure (ICP). Eye compresses may be used for localized ocular conditions (e.g., stye, conjunctivitis), not neurological or intracranial pathology.
Implement seizure precautions (Anticipated): A pituitary adenoma with neurologic symptoms (confusion, restlessness, headache, vomiting) suggests possible increased ICP or brain irritation. These conditions increase seizure risk, so seizure precautions (padding side rails, suction setup, airway protection) are appropriate.
Administer furosemide (Anticipated): Furosemide is a loop diuretic that can help reduce intracranial pressure by decreasing cerebral edema and fluid volume. It is appropriate in suspected ICP elevation.
Administer 0.9% sodium chloride 1000 mL IV at 150 mL/hr (Unanticipated): Large-volume isotonic fluid administration may worsen cerebral edema and increase ICP. In patients with suspected elevated ICP, fluid management must be cautious to avoid exacerbation of brain swelling.
Administer dexamethasone (Anticipated): Dexamethasone is a corticosteroid that reduces cerebral edema and is commonly used in pituitary tumors or brain masses to decrease inflammation and ICP-related symptoms.

A. Ventrogluteal B. Forearm C. Abdomen D. Upper back

Correct Answer is A

Explanation

A. The ventrogluteal site is the preferred site for intramuscular (IM) injections in adults. It is well-developed, has a large muscle mass, and is free of major nerves and blood vessels, making it the safest and most reliable site. It also allows for better absorption of medication and reduces the risk of complications such as nerve injury.

B. The forearm is typically used for intradermal injections, such as tuberculosis (TB) testing. It does not have sufficient muscle mass for intramuscular injections.

C. The abdomen is commonly used for subcutaneous injections, such as insulin or heparin. It is not an appropriate site for intramuscular injections due to insufficient muscle depth and increased risk of improper administration.

D. The upper back is not a standard or recommended site for intramuscular injections. While some areas of the back contain muscle, they are not commonly used due to difficulty in access and risk of injury to underlying structures.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in a clinic. For each intervention, click to specify if the intervention is anticipated or unanticipated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A nurse is preparing to administer an intramuscular injection to a client. Which of the following injection sites should the nurse choose to utilize?

Correct Answer is A

Explanation

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