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Nurses' Notes

Day 1, 1030:

Client reports feeling short of breath, productive cough with yellow sputum, and pleuritic chest pain. Runny nose, myalgia along with headache for the past 3 days. "I woke up feeling worse and started to feel nauseated and couldn't eat my breakfast, so I thought I should come in." Client reports pleuritic chest pain as 6 on a scale of 0 to 10. Skin is moist. Lungs sounds are diminished in lower lobes with crackles. Bowel sounds are normoactive in all quadrants. Last bowel movement this morning. Reports no difficulty urinating Reports nausea with no vomiting. Able to move all extremities. Pedal pulses present +2. Client is oriented to person, place, and time.

Client reports feeling short of breath, productive cough with yellow sputum, and pleuritic chest pain

Client reports pleuritic chest pain as 6 on a scale of 0 to 10

Skin is moist

Lungs sounds are diminished in lower lobes with crackles.

Bowel sounds are normoactive in all quadrants

Reports nausea with no vomiting

Able to move all extremities

Pedal pulses present +2

Answer and Explanation

The Correct Answer is ["A","B","D"]

Rationale for correct choices

• Shortness of breath: The client’s dyspnea indicates impaired oxygenation and potential progression of pneumonia or respiratory compromise. Rapid recognition is essential to prevent hypoxemia or respiratory failure. Persistent shortness of breath warrants immediate interventions such as supplemental oxygen, monitoring, and notifying the provider.

• Productive cough with yellow sputum: The sputum color and productivity suggest a bacterial respiratory infection, which is confirmed by the chest x-ray result (pneumonia) and elevated WBC count. This requires immediate treatment with antibiotics.

• Diminished lung sounds with crackles: Diminished breath sounds and crackles suggest alveolar consolidation or fluid accumulation in the lungs, consistent with pneumonia. These findings indicate impaired gas exchange and increased work of breathing. Prompt assessment ensures early intervention and prevents deterioration.

• Pleuritic chest pain rated 6/10: Moderate chest pain on inspiration can indicate inflammation of the pleura secondary to pneumonia or early complications such as empyema. Pain may limit deep breathing and coughing, increasing the risk of atelectasis and further respiratory compromise. Follow-up ensures pain management and effective pulmonary hygiene.

Rationale for Incorrect Findings

• Nausea without vomiting: While the client reports nausea, it is mild and not associated with dehydration or electrolyte disturbances at this time. It should be monitored but does not require immediate intervention.

• Able to move all extremities and oriented: Neurological status is intact, which is reassuring. No deficits are noted, and immediate follow-up is not required.

• Skin is moist, pedal pulses +2: Perfusion appears adequate. Vital signs and circulation findings do not indicate acute compromise needing urgent intervention.

• Bowel sounds normoactive, last bowel movement this morning, no difficulty urinating: Gastrointestinal and urinary functions are stable. These findings do not require immediate follow-up.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale for correct choices

• Stroke: The client developed new-onset atrial fibrillation with a rapid ventricular response, which significantly increases the risk for thrombus formation and subsequent embolic stroke. Atrial fibrillation after cardiac surgery can lead to stasis of blood in the atria, particularly the left atrial appendage, predisposing the client to cerebrovascular events.

• Cardiac rhythm: Monitoring cardiac rhythm is essential because changes such as atrial fibrillation, tachyarrhythmias, or pauses indicate altered hemodynamics and potential complications. The irregular, rapid atrial fibrillation observed at 1130 highlights the client’s immediate risk for embolic events. Continuous cardiac monitoring allows prompt recognition and intervention to prevent stroke

Rationale for incorrect choices

• Atelectasis: Atelectasis would present with diminished lung sounds, crackles, dyspnea, or hypoxemia. In this case, lung sounds are clear bilaterally, oxygen saturation is slightly decreased but not critically low, and the client reports no respiratory distress. These findings make atelectasis less likely.

• Cardiac tamponade: Cardiac tamponade is characterized by hypotension, jugular venous distension, muffled heart sounds, and tachycardia. Although the client has tachycardia, blood pressure is only mildly decreased, JVD is absent, and heart sounds are normal. These findings do not support cardiac tamponade at this time.

• Pneumothorax: Pneumothorax would present with diminished or absent lung sounds on the affected side, sudden dyspnea, and decreased oxygen saturation. Lung sounds are clear bilaterally, chest tubes are patent, and oxygen saturation is only slightly decreased, which is insufficient evidence for pneumothorax.

• Infection: Early postoperative infection might present with fever, redness, or drainage at surgical sites. The client’s dressings are clean, dry, and intact, with only a mild temperature elevation, which may be a normal postoperative response rather than a true infection. There is no other clinical evidence to support infection as an immediate concern.

• Chest tube assessment: Chest tube assessment is important for monitoring pneumothorax or fluid accumulation but is not related to the immediate risk of stroke. The chest tubes are patent, with tidaling present and no air leak, indicating proper function. This parameter does not reflect the client’s thromboembolic risk.

• Lung sounds: Lung sounds are clear and do not indicate respiratory compromise or atelectasis. While important for overall assessment, lung auscultation does not provide evidence of the client’s risk for stroke in the context of new atrial fibrillation.

• Heart sounds: Heart sounds are normal with no extra sounds or murmurs. While auscultation is part of cardiac assessment, the primary risk for stroke is related to the cardiac rhythm rather than auscultatory findings.

• Dressing assessment: Dressings are clean, dry, and intact, indicating no current surgical site complications. This parameter does not contribute to identifying the client’s stroke risk.

A. Decrease intake of citrus foods and beverages. B. Wear nylon underwear. C. Empty the bladder before and after intercourse. D. Increase the time between voiding.

Correct Answer is C

Explanation

A. Decrease intake of citrus foods and beverages: Citrus foods and beverages do not increase the risk of UTIs and may actually support general health through vitamin C. Restricting them is unnecessary and not part of standard UTI prevention education.

B. Wear nylon underwear: Nylon underwear is less breathable than cotton and can increase moisture, promoting bacterial growth. Clients should be advised to wear cotton underwear to reduce UTI risk.

C. Empty the bladder before and after intercourse: Urinating before and after sexual activity helps flush bacteria from the urethra, reducing the risk of infection. This is an effective and recommended preventive measure for clients with a history of UTIs.

D. Increase the time between voiding: Holding urine for extended periods allows bacteria to multiply in the urinary tract and increases the risk of infection. Clients should be advised to void regularly to prevent UTIs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is on the cardiac step-down unit. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing _____ as evidenced by their ______

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections (UTIs). Which of the following information should the nurse plan to include in the teaching about UTI prevention?

Correct Answer is C

Explanation

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