Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Take and monitor vital signs.

Administer additional nebulizer treatment.

Increase oxygen flow rate.

Raise the head of the bed.

Provide client with a spirometer for use.

Answer and Explanation

Correct Answer : B,C,D

Choice A reason: Monitoring vital signs is crucial to assess the client's current condition and detect any further deterioration. Changes in vital signs can indicate the effectiveness of the treatment and whether additional interventions are needed. For instance, if the heart rate continues to rise or oxygen saturation drops further, it suggests that the client's condition is worsening and requires immediate attention. Keeping a close eye on the vital signs helps the healthcare team to make timely decisions and adjust the treatment plan as necessary.

Choice B reason: Administering additional nebulizer treatment is necessary because the client is still experiencing shortness of breath and bilateral wheezes even after the initial medication. Nebulizer treatments, such as those containing albuterol and ipratropium, help to relax and open the airways, making breathing easier. Given the client's severe asthma symptoms and the fact that the previous doses were not completely effective, additional treatment can provide the needed relief and prevent further respiratory distress.

Choice C reason: Increasing the oxygen flow rate is essential to improve the client's oxygen saturation levels. The current oxygen saturation of 91% indicates hypoxemia, which can lead to severe complications if not addressed promptly. By increasing the flow rate, the client can receive a higher concentration of oxygen, helping to maintain adequate oxygenation of tissues and organs. Continuous monitoring of oxygen saturation is also important to ensure that the increased flow rate is effective and to make further adjustments if needed.

Choice D reason: Raising the head of the bed helps to facilitate easier breathing for the client. This position allows gravity to assist in the expansion of the lungs and reduces the pressure on the diaphragm, making it easier for the client to take deeper breaths. It also helps to reduce the work of breathing and can be particularly beneficial for clients experiencing respiratory distress. Ensuring that the client is in a comfortable and optimal position for breathing is an important aspect of asthma management.

Choice E reason: While providing a spirometer can be useful for lung function exercises, it is not the immediate priority in this acute situation. The client's primary concern is to stabilize their breathing and ensure adequate oxygenation. Once the client is stable, a spirometer can be introduced as part of long-term management and rehabilitation to improve lung function and monitor progress.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: A fasting serum glucose level of 140 mg/dL (7.77 mmol/L) indicates hyperglycemia, which is elevated but not an immediate life-threatening complication. It suggests poor blood glucose control but does not directly indicate a complication specific to type 2 diabetes and hypertension. This value should prompt further evaluation and adjustments in diabetes management, but it is not as critical as other potential findings.

Choice B reason: A glycosylated hemoglobin (A1c) level of 6.9% is within the range of good diabetic control. While it indicates the client has been managing their blood glucose levels relatively well over the past few months, it does not suggest a current complication. This value is used to assess long-term glucose control rather than acute issues.

Choice C reason: A serum creatinine level of 1.6 mg/dL (141.44 umol/L) is elevated and indicates impaired kidney function. Clients with type 2 diabetes mellitus and hypertension are at increased risk for kidney disease, known as diabetic nephropathy or hypertensive nephropathy. Elevated creatinine levels suggest that the kidneys are not filtering waste products effectively, which is a significant complication that requires immediate attention and intervention.

Choice D reason: A white blood cell (WBC) count of 11,000/mm3 (11 x 10^9/L) is slightly elevated and may suggest an infection or inflammation. However, it is not a specific complication related to type 2 diabetes mellitus and hypertension. Elevated WBC counts warrant further investigation to identify any underlying infection or inflammatory process, but it is not as directly related to diabetic or hypertensive complications as elevated serum creatinine.

A. Complete blood count B. Platelet count C. Serum electrolytes D. Liver enzymes

Correct Answer is A

Explanation

Choice A reason: A complete blood count (CBC) is the most relevant laboratory value to review for a client with iron deficiency anemia who reports increased fatigue. The CBC will provide important information about the levels of red blood cells, hemoglobin, and hematocrit, which are directly affected by iron deficiency. Monitoring these values will help determine if the client’s anemia is worsening or if the iron supplements are not effectively improving the blood count.

Choice B reason: The platelet count is part of a CBC but is not directly related to the symptoms of fatigue in iron deficiency anemia. While platelet levels are important for assessing clotting function, they do not provide the necessary information about red blood cell levels or hemoglobin concentration that are central to diagnosing and managing anemia.

Choice C reason: Serum electrolytes are important to monitor for overall health and hydration status, but they are not specifically related to the client’s anemia or the symptom of fatigue. Electrolyte imbalances typically do not cause fatigue related to anemia, so this is not the primary laboratory value to review in this context.

Choice D reason: Liver enzymes are important for assessing liver function and potential liver damage, but they are not directly related to iron deficiency anemia or the symptom of fatigue. While it is important to monitor liver health, especially if the client is on medications that affect the liver, the complete blood count is more relevant to the symptoms described.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client who takes daily supplemental iron tablets for iron deficiency anemia reports feeling increasingly fatigued. Which laboratory value should the nurse review?

Correct Answer is A

Explanation

A client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to wake during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?

A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?a) Cerebrovascular accident (CV

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.