A nurse caring for a client who is at home on hospice care.

Exhibits

At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

Client calm not agitated. Grimaces with movement.

Oral mucous membranes dry.

Axillary temp 102 F (38.9 C), client shivering.

Productive cough.

Coarse rhonchi bilaterally. Crackles in bases.

Respirations irregular with periods of apnea

Client resting in recliner. RR 12, regular

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}

Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.

No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.

Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.

No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.

Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.

Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.

Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.

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

Explanation

The nurse should first place the client in high Fowler's position to ease the breathing and improve oxygenation, as the client is experiencing increased dyspnea and chest pain. This position allows for better lung expansion and can be a critical immediate intervention. Following this, the nurse should obtain IV access to facilitate the administration of medications and fluids as needed. IV access is essential for the rapid administration of potential treatments, including anticoagulants, which may be required if a pulmonary embolism is confirmed. These actions are prioritized to address the client's immediate respiratory distress and to prepare for further interventions based on the evolving clinical situation. It is important to note that each clinical scenario is unique, and the interventions should be tailored to the client's specific needs and the healthcare provider's clinical judgment.

A. The client has a history of bronchial asthma. B. The client has a history of migraine headaches. C. The client has a history of hypertension. D. The client has a history of hypothyroidism.

Correct Answer is A

Explanation

A. The client has a history of bronchial asthma: Propranolol is a non-selective beta-blocker and can potentially exacerbate bronchospasm in individuals with asthma due to its beta-blocking effects on beta-2 receptors in the bronchioles. Therefore, this finding should be reported to the provider for further assessment and consideration of alternative medications.

B. The client has a history of migraine headaches: Propranolol is commonly used prophylactically to prevent migraine headaches, so this finding is not a contraindication for its use and does not require immediate reporting to the provider.

C. The client has a history of hypertension: Propranolol is often prescribed for hypertension, so this finding is expected and not a cause for concern.

D. The client has a history of hypothyroidism: While propranolol can affect thyroid function tests, a history of hypothyroidism alone is not a contraindication for its use, and it does not

require immediate reporting to the provider. However, thyroid function should be monitored during therapy.

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A nurse caring for a client who is at home on hospice care. Exhibits At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department (ED). Exhibits The nurse should first followed by

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

Explanation

A nurse is reviewing the health history of a client diagnosed with angina pectoris and has a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the client's health history should the nurse report to the provider?

Correct Answer is A

Explanation

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A nurse caring for a client who is at home on hospice care.

Exhibits

At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.