A client arriving to the emergency department reports trouble breathing and tightness in the chest that started while exercising at the gym. The nurse observes the client is afebrile, heart rate 96 beats/minute, respirations 32 breaths/minute, and pulse oximeter reading of 85%. Audible wheezing is heard on expiration with a decrease in tactile fremitus and bilateral breath sounds. The client displays intercostal retracting and prolonged expirations. Based on the findings, the nurse should recognize the client is exhibiting symptoms of which condition?

Pneumonia.

Pneumothorax.

Asthma.

Bronchitis.

Answer and Explanation

The Correct Answer is C

A. Pneumonia typically presents with fever, productive cough, and lung consolidation, not just wheezing and low oxygen saturation.
B. Pneumothorax usually causes sudden sharp chest pain and decreased breath sounds on the affected side, rather than wheezing and prolonged expiration.
C. Asthma is characterized by wheezing, prolonged expiration, and low oxygen saturation due to bronchoconstriction and inflammation. The client's symptoms are consistent with an asthma exacerbation.
D. Bronchitis presents with a productive cough and sometimes wheezing but does not typically cause such severe hypoxemia or a pronounced increase in respiratory rate as seen here.

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Correct Answer is C

Explanation

A. Jaundice is not related to oxygen saturation, so using a pulse oximeter is not appropriate in this situation.
B. Reducing the dose of acetaminophen may be necessary, but this decision should be made after evaluating liver function.
C. Jaundice, characterized by yellowing of the skin, can indicate liver dysfunction, possibly due to acetaminophen overuse or toxicity. The nurse should report this finding to the healthcare provider immediately for further evaluation and management.
D. Checking capillary glucose levels is not relevant to the assessment of jaundice.

A. Administer a prescribed antianxiolytic. B. Allow the client to rest before taking the vital signs. C. Notify the client representative. D. Offer the client hot tea to promote relaxation.

Correct Answer is B

Explanation

A. Administering an antianxiolytic might be premature and should only be done if prescribed and necessary.
B. Allowing the client to rest before taking vital signs helps ensure that the measurements are accurate and not influenced by recent emotional distress.
C. Notifying the client representative might be relevant later, but addressing the client's immediate needs and emotional state is the priority.
D. Offering hot tea may not be appropriate in this situation and does not directly address the need for accurate vital signs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to Include in the discharge teaching?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin? Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 109/L)]

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

The nurse is caring for a client who is taking the mood stabilizer divalproex sodium. Which laboratory value is most important for the nurse to monitor?

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?