The nurse is caring for a client experiencing tachypnea, dyspnea, and confusion. Which of the following orders does the nurse anticipate receiving from the healthcare provider? Select all that apply
Chest x-ray
Complete Blood Count (CBC)
Magnetic resonance imaging (MRI) of chest with contrast
Arterial blood gases (ABGs)
Lactate level
Correct Answer : A,B,D,E
A. A chest x-ray helps identify pulmonary causes of dyspnea, such as pneumonia, pulmonary edema, pneumothorax, or pleural effusion, which could explain the client’s tachypnea and hypoxia.
B. CBC can detect infection (elevated WBCs), anemia (low hemoglobin), or other hematologic abnormalities that may contribute to confusion, hypoxia, or respiratory compromise.
C. MRI is rarely used as an initial diagnostic tool for acute respiratory distress or confusion because it is time-consuming and not ideal for unstable patients. It is generally reserved for detailed evaluation of mediastinal masses or vascular abnormalities.
D. ABGs provide immediate information about oxygenation, ventilation, and acid-base status, which is critical in a client with tachypnea, dyspnea, and confusion to guide oxygen therapy and interventions.
E. Elevated lactate levels indicate tissue hypoperfusion and anaerobic metabolism, which may be present in sepsis or shock. This test helps assess the severity of the client’s condition and monitor response to interventions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Localized infiltrates indicate a focal process, such as bacterial pneumonia or aspiration in a single lobe. ARDS affects the lungs diffusely, so a localized pattern would not support the diagnosis.
B. Cardiomegaly is associated with cardiogenic pulmonary edema, where heart failure causes fluid accumulation in the lungs. In ARDS, the pulmonary edema is non-cardiogenic, and the heart size is typically normal.
C. In ARDS, the alveoli fill with fluid, protein, and inflammatory cells, causing widespread opacification on chest x-ray. This appears as bilateral, patchy, or confluent “white-out” infiltrates, indicating severe alveolar involvementand impaired oxygenation. These findings correlate with the patient’s rapidly worsening hypoxemia and respiratory distress.
D. Hyperinflation is characteristic of obstructive airway diseaseslike COPD or asthma, where air is trapped in the lungs. In ARDS, the lungs are stiff and noncompliant, so hyperinflation does not occur.
Correct Answer is B
Explanation
A. Mediastinal chest tubes are specific for draining fluid or blood from the mediastinum after cardiac surgery, but the description in the question refers to the suction mechanism of the drainage system, not its anatomical placement.
B. A dry suction systemuses a mechanical suction monitor (bellow or dial)rather than a water column to regulate suction. It allows precise suction control, eliminates bubbling noises, and does not require water replenishment, preventing evaporation issues. This matches the description provided.
C. Wet suction systems use a water column to control suction. Bubbling in the water chamber regulates suction, and water can evaporate over time, which is different from the dry suction system described.
D. Dry-wet systems combine features of both dry and water-based suction systems, but the description specifies no water column is used to control suction, which aligns solely with the dry suction system.
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