A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Administer oxygen to the client.

Notify the charge nurse.

Document client findings and interventions taken.

Place the client in high Fowler's position.

Answer and Explanation

The Correct Answer is D,A,B,C

D. Place the client in high Fowler’s position. Positioning the client upright maximizes lung expansion and improves oxygenation. This is the first step to alleviate respiratory distress before additional interventions.

A. Administer oxygen to the client. Once the client is positioned appropriately, providing supplemental oxygen helps increase oxygen saturation and relieve hypoxia. The nurse should titrate oxygen as needed according to facility protocols or provider orders.

B. Notify the charge nurse. After immediate interventions are in place, the nurse should inform the charge nurse to ensure further assessment and necessary medical interventions. The charge nurse may escalate care or contact the provider for additional management.

C. Document client findings and interventions taken. Once the client’s condition has been addressed and reported, documentation is necessary to record assessment findings, interventions provided, and the client's response. Accurate documentation ensures continuity of care and legal protection.

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

Explanation

Chronic kidney disease. The client's laboratory results show elevated BUN and creatinine levels, which are indicative of impaired kidney function. A creatinine level of 4.89 mg/dL (normal range 0.5 to 1.1 mg/dL) and BUN of 70 mg/dL (normal range 10 to 20 mg/dL) suggest a decline in kidney function, which is characteristic of chronic kidney disease (CKD). The increasing creatinine levels and the elevated BUN over time point toward worsening kidney function, which may lead to kidney failure if not managed appropriately.
Dialysis. In the setting of advanced chronic kidney disease, particularly when kidney function deteriorates to a point where the kidneys can no longer adequately filter waste products from the blood, dialysis is often required. The increasing levels of creatinine and BUN indicate that the kidneys may be unable to function properly without intervention, potentially necessitating dialysis for proper waste management and fluid balance.

Rationale for Incorrect Options:

Heart failure: While the client has some evidence of fluid retention (1+ bilateral lower extremity edema), this alone is insufficient to confirm heart failure, especially since the heart sounds were noted as normal (S1, S2, no murmur). Further assessment is needed to evaluate the heart's pumping ability, including echocardiogram or other diagnostic tests.
Hypothyroidism: Although the client has dry, flaky skin and fatigue, these symptoms are not definitive for hypothyroidism. Thyroid function tests would be necessary to confirm the diagnosis.
Anemia: Although the client has slightly low hemoglobin (13 g/dL, normal is 14 to 18 g/dL) and hematocrit, this may be due to chronic kidney disease, and it does not directly indicate anemia without further evidence, such as low iron levels or additional laboratory findings.
Diuretic therapy: While diuretics are used in heart failure or fluid overload conditions, they are not indicated here for the management of chronic kidney disease unless there is fluid retention related to heart failure or other conditions.
Thyroid replacement therapy: There is no evidence from the client's lab results or clinical presentation suggesting hypothyroidism, so thyroid replacement therapy would not be indicated at this time.
Iron supplementation: While the client has a low iron saturation (24%), this alone does not warrant iron supplementation without a definitive diagnosis of iron-deficiency anemia. Further testing would be required to confirm this.

Correct Answer is []

Explanation

Potential Condition:

Kawasaki disease: The child presents with prolonged fever, mucocutaneous changes (cracked lips, red tongue), extremity changes (edema, peeling skin), cervical lymphadenopathy, and elevated inflammatory markers (WBC, ESR, CRP, and platelets), all of which are consistent with Kawasaki disease.

Actions to Take

Administer IVIG: IVIG is the primary treatment to reduce inflammation and prevent coronary artery aneurysms.

Administer high-dose aspirin: Used in the acute phase to reduce inflammation and fever and in the subacute phase to prevent clot formation.

Parameters to Monitor

Heart rhythm: Kawasaki disease can cause myocarditis and coronary artery aneurysms, leading to arrhythmias.

Chest discomfort: A sign of coronary artery complications, including aneurysms or ischemia.

Rationale for Incorrect Diagnoses:

Bacterial endocarditis: Does not cause peeling skin or bright red tongue. Fever would be accompanied by murmurs and a history of heart defects.

Nephrotic syndrome: Characterized by severe proteinuria, edema, and hypoalbuminemia, which are absent here.

Acute post-streptococcal glomerulonephritis: Would present with recent strep infection, hematuria, hypertension, and periorbital edema, which are not mentioned.

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A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client in an outpatient provider's office Exhibits Complete the following sentence by using the list of options. The nurse should identify that the client is at risk of developing dropdownand may requiredropdown

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

Explanation

Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is likely experiencing, 2 actions the nurse should take to address the condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Correct Answer is []

Explanation

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