The nurse is caring for a client.
Complete the following sentence by using the lists of options.
The client is most likely experiencing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Rationale for correct choices:
- Pulmonary embolism: The client presents with sudden dyspnea, chest discomfort, tachypnea, tachycardia, hypoxia, and anxiety (“something is really wrong”), which are hallmark signs of a pulmonary embolism. The rapid onset is key—PE typically presents abruptly rather than gradually. Although crackles and S3/S4 may suggest fluid overload, the acute respiratory distress in a postoperative client strongly prioritizes PE as the most life-threatening and likely cause.
- Recent surgery: Total hip arthroplasty significantly increases risk for venous thromboembolism (VTE) due to immobility, venous stasis, endothelial injury, and hypercoagulability (Virchow’s triad). Clots formed in the deep veins can dislodge and travel to the lungs, causing a pulmonary embolism. This makes recent orthopedic surgery the strongest contributing factor.
Rationale for incorrect choices:
- Pneumonia: Typically develops gradually, with cough, sputum production, and localized lung findings, not sudden severe dyspnea and chest pain.
- Pneumothorax: Usually presents with unilateral absent breath sounds and sudden chest pain, not bilateral crackles.
- Activity level: The client was previously active and ambulated postoperatively; activity level does not explain the acute event.
- Tobacco use: The client denies tobacco use, so it is not a contributing factor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Absence seizures begin abruptly and end just as suddenly. There is no gradual progression of symptoms. The child may be talking or engaged in an activity and suddenly “freeze” without warning. This sudden interruption is a key distinguishing feature from other neurological or behavioral conditions.
B. Absence seizures are typically very brief, lasting about 5–15 seconds (sometimes up to ~20 seconds). During the episode, the child may have a blank stare, slight eyelid fluttering, or subtle automatisms (such as lip smacking), and then immediately resume normal activity with no postictal confusion. A duration of 30–60 seconds would be more suggestive of other seizure types.
C. Absence seizures do not have an aura or warning signs. Auras are more characteristic of focal (partial) seizures where a localized brain region produces sensory or emotional premonitory symptoms (such as a strange smell, déjà vu, or tingling). In absence seizures, the onset is too rapid for a warning phase to occur.
D. Absence seizures often appear as brief staring spells where the child suddenly stops activity, becomes unresponsive, and may blink or exhibit subtle facial movements. Because the episode is so short and the child quickly returns to baseline without confusion, teachers and parents may assume the child is simply daydreaming or not paying attention. This misinterpretation is very common, especially in school-aged children, which is why awareness is important for early recognition and treatment.
Correct Answer is D
Explanation
A. A pain level of 4/10 is considered mild to moderate pain and is expected in the early postoperative period following a total abdominal hysterectomy. This level of pain can typically be managed with prescribed analgesics and does not require immediate provider notification.
B. A small (scant) amount of dark red drainage is expected within the first several hours after surgery due to residual bleeding at the surgical site. As long as the drainage is not increasing, bright red, or excessive, it is considered a normal postoperative finding.
C. Decreased or absent bowel sounds are expected in the early postoperative period due to the effects of anesthesia and bowel manipulation during surgery. This condition, known as postoperative ileus, is common and usually resolves gradually.
D. Urinary output should be at least 30 mL/hr in an adult. Over 3 hours, the expected minimum output is 90 mL. An output of 75 mL (25 mL/hr) indicates oliguria, which may suggest hypovolemia, decreased renal perfusion, or possible complications such as hemorrhage. This finding requires prompt reporting to the provider for further evaluation and intervention.
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