A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

Assess respiratory rate and rhythm

Pulse oximetry reading

Assess bowel sounds

Auscultate lung sounds

Determine two touch discrimination in the lower extremities

Answer and Explanation

Correct Answer : A,B,D

A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.

B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.

C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.

D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.

E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.

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Correct Answer is ["A","C","E"]

Explanation

A. Check the client's toes for color, temperature, and sensation: Assesses neurovascular status to detect signs of impaired circulation or nerve injury.

B. Apply heat to the client's ankle: Heat can increase swelling; ice should be used instead (RICE method: Rest, Ice, Compression, Elevation).

C. Apply a compression bandage to the client's ankle: Helps reduce swelling and provides support.

D. Encourage range of motion of the client's foot: Movement may worsen injury if a fracture or soft tissue damage is present.

E. Elevate the client's foot: Reduces swelling by promoting venous return.

A. Allow the perineal area to air dry after each stool. B. Administer a soap-suds enema to cleanse the colon. C. Provide the client with a high fiber diet. D. Apply a zinc-oxide barrier to the perineal area after each stool.

Correct Answer is D

Explanation

A. Allow the perineal area to air dry after each stool. While drying is important, leaving the skin unprotected can lead to skin breakdown and irritation from continued exposure to stool.

B. Administer a soap-suds enema to cleanse the colon. Soap-suds enemas are contraindicated in diarrhea because they can cause further irritation and electrolyte imbalances.

C. Provide the client with a high-fiber diet. A high-fiber diet is recommended for constipation, not diarrhea, as fiber can increase stool frequency.

D. Apply a zinc-oxide barrier to the perineal area after each stool. Zinc-oxide protects the skin from moisture and irritation, helping prevent dermatitis and skin breakdown.

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A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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