The nurse is continuing to assist in the care of the client.
Exhibits
For each data collection finding, click to specify if the finding on postoperative day 1 is consistent with hypovolemic shock or pulmonary embolism. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.
Heart rate
Respiratory effort
Pain
Blood pressure
Mentation
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}
Heart rate
• Hypovolemic Shock
o The elevated heart rate of 104/min is consistent with hypovolemic shock, where the body compensates for reduced blood volume by increasing heart rate to maintain cardiac output and perfusion.
• Pulmonary Embolism
o An increased heart rate can also occur with pulmonary embolism as the body responds to decreased oxygenation and impaired cardiac function.
Respiratory effort
• Hypovolemic Shock
o Increased respiratory rate of 24/min may be a compensatory mechanism in hypovolemic shock to enhance oxygen delivery to tissues despite reduced blood volume.
• Pulmonary Embolism
o Elevated respiratory rate can also be seen in pulmonary embolism due to impaired gas exchange and increased respiratory effort to compensate for decreased oxygen levels.
Pain
• Pulmonary Embolism
o Pain, particularly pleuritic chest pain, is a common symptom of pulmonary embolism and could be indicative of embolic obstruction in the pulmonary circulation.
Blood pressure
• Hypovolemic Shock
o The drop in blood pressure to 88/54 mm Hg is consistent with hypovolemic shock, where reduced blood volume leads to decreased perfusion and hypotension.
Mentation
• Hypovolemic Shock
o Altered mentation, such as restlessness or agitation, can be a sign of hypovolemic shock as decreased perfusion affects brain function and consciousness.
• Pulmonary Embolism
o Changes in mentation can also occur in pulmonary embolism due to hypoxemia or decreased perfusion to the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
1. Bumetanide 1 mg IV stat: The client’s vital signs show hypotension (blood pressure 88/54 mm Hg) and tachycardia (heart rate 104/min). The skin is cool and moist, and capillary refill is delayed, suggesting possible fluid overload or heart failure. Bumetanide is a potent diuretic used to address fluid overload and reduce the heart's workload.
2. Packed red blood cells: The client’s urine output is low (110 mL over 6 hours), which, combined with signs of hypotension and tachycardia, may indicate significant blood loss or anemia. Administering packed red blood cells can help correct anemia and improve blood volume.
Correct Answer is C
Explanation
A. Presence of gag reflex: This is normal after a bronchoscopy as the gag reflex indicates that the client is recovering from sedation.
B. Sore throat: This is a common and expected finding after a bronchoscopy due to irritation of the throat.
C. Facial edema: This is correct as facial edema may indicate an allergic reaction or complication, and it should be reported to the provider immediately.
D. Blood pressure 110/78 mm Hg: This is within the normal range and does not typically require reporting unless there are other symptoms present.
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