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.

Apply a nonrebreather oxygen mask.

Increase oxygen flow.

Raise the head of the bed.

Take and monitor vital signs.

Administer additional nebulizer treatment as prescribed.

Provide client incentive spirometer and instruct on use

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Apply a nonrebreather oxygen mask. This will help increase the oxygen concentration delivered to the client's lungs and improve oxygen saturation.

B. Increase oxygen flow. Increasing the oxygen flow rate can help to further improve oxygen delivery.

C. Raise the head of the bed. This can help improve lung expansion and facilitate breathing.

D. Take and monitor vital signs. This will help assess the client's response to interventions and identify any deterioration.

E. Administer additional nebulizer treatment as prescribed. If the client's symptoms are not improving, additional nebulizer treatments may be necessary.

F. Provide client incentive spirometer and instruct on use: While incentive spirometry can be helpful in preventing atelectasis, it is not a priority in this acute situation where the client's immediate need is to improve oxygenation and reduce airway obstruction.

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Correct Answer is A

Explanation

A. Administering opioid and non-opioid medications together is an effective pain management strategy for severe pain. This approach can provide better pain relief by targeting different pain pathways and may reduce the total dosage of opioids needed, thus minimizing side effects.

B. Alternating IV and IM analgesic medications is not the best approach; instead, consistent pain management is necessary to keep pain levels under control.

C. Waiting until the pain score reaches 10 before administering the maximum dosage is inappropriate and could lead to inadequate pain control. Pain management should be proactive, not reactive.

D. While educating the client on narcotic dependency is important, it is not the priority intervention in this acute situation where pain control is essential. The immediate focus should be on effective pain relief.

A. Hematocrit. B. Blood pH level. C. Platelet count. D. White blood cell (WBC) count.

Correct Answer is D

Explanation

A. While hematocrit levels provide information about blood volume status, they are not directly relevant to infection status or wound healing in burn patients.

B. Blood pH levels can indicate acid-base imbalances, but they do not specifically inform the nurse about the presence of infection.

C. Platelet count is important for assessing coagulation and bleeding risks, but it does not provide direct information regarding infection.

D. White blood cell (WBC) count is critical in assessing for infection, as an elevated WBC count can indicate the presence of an infection, particularly in a client with significant burns who is at increased risk for sepsis.

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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.

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Naxlex Comprehensive Predictor Exams

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?

Correct Answer is A

Explanation

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Correct Answer is D

Explanation

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A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

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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.