How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.

A.

Heart rate

B.

Respiratory effort

C.

Pain

D.

Blood pressure

E.

Mentation

Answer and Explanation

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.


 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

A. A padded tongue blade: A padded tongue blade is not recommended as it can cause injury to both the client and the nurse. It is a common misconception that it should be used during a seizure, but it does not prevent injury.
B. Anticonvulsant medication: While important for managing seizures, anticonvulsant medication is not an equipment item to be placed at the bedside. It is typically administered as per the prescription and monitored by healthcare providers.
C. A nasogastric tube: A nasogastric tube is not relevant for seizure precautions and is used for different medical purposes, such as feeding or gastric decompression.
D. A suction machine: This is correct as a suction machine is essential to clear the airway in case of aspiration during or after a seizure. It helps in maintaining airway patency and preventing complications.

Correct Answer is C

Explanation

A. "I will have hot, dry, and flushed skin if I am having a heart attack": This statement is incorrect as it does not accurately reflect typical symptoms of a heart attack. Common symptoms include chest pain, shortness of breath, and possibly cold sweat, not hot, dry, and flushed skin.
B. "I will wait 30 minutes before taking action if I have heartburn": Waiting 30 minutes before taking action is incorrect for angina or heartburn. Immediate action is required for angina symptoms, and heartburn should be differentiated from angina by a healthcare provider.
C. "I will notify emergency response if I have sudden jaw pain": This statement is correct because sudden jaw pain can be a symptom of angina or a heart attack, indicating that immediate medical attention is needed.
D. "I will take four nitroglycerin sublingual tablets if I have chest pain": This statement is incorrect as taking four nitroglycerin tablets is excessive and could be harmful. The standard recommendation is to take one tablet every 5 minutes for up to three doses if chest pain persists, and then seek medical attention.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register