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Exhibits

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Discuss aggressive respiratory treatment options

Obtain a sputum culture

Monitor the oxygen saturation

Allow the client to take a position of comfort

Wean the supplemental oxygen

Prepare for deep tracheal suctioning

Consider positive pressure ventilation

Discuss with the client potential asthma triggers

Answer and Explanation

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

A. While discussing treatment options is important, it may not be immediately necessary at this point unless the client shows signs of severe respiratory distress or failure.

B. Given the client's respiratory distress and recent cold symptoms, obtaining a sputum culture can help identify any underlying infection, which is important for appropriate treatment, particularly with the prescribed azithromycin.

C. Continuous monitoring of oxygen saturation is essential to ensure that the client's oxygen levels are adequate, especially since she is at risk for hypoxia. The goal is to maintain oxygen saturation greater than 94%.

D. Positioning the client in a way that enhances her comfort, such as sitting upright, can help improve her breathing and reduce respiratory distress. This is a fundamental nursing intervention in respiratory care.

E. If the client's oxygen saturation improves, the nurse can begin to wean the supplemental oxygen while monitoring for any signs of respiratory distress. This step should be approached cautiously to ensure the client maintains adequate oxygen levels.

F. There is no indication that the client requires deep tracheal suctioning at this moment. This action is reserved for patients with excessive secretions or compromised airway patency.

G. Positive pressure ventilation would typically be considered if the client were in severe respiratory distress or failure. The current assessment does not indicate an immediate need for this intervention.

H. Education on potential asthma triggers is crucial for the client's long-term management. This discussion can help the client avoid situations that could lead to future exacerbations, thus improving her overall asthma control.

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Correct Answer is D

Explanation

A. Declining to take ice chips despite reporting of dry mouth: While this is noteworthy, it is less critical than abdominal assessment findings for a postoperative laparotomy client.

B. Peripheral pulses present with full range of motion of both legs: This is important for assessing circulation and mobility but is less urgent than the abdominal assessment in this context.

C. History of vomiting at home for 3 days prior to surgery: Although relevant to the overall medical history, this information is not as immediately critical in the postoperative period compared to the current physical findings.

D. Soft abdomen, absent bowel sounds, no bleeding on dressing: Postoperative assessment of the abdomen is crucial for clients who have undergone abdominal surgery. The presence or absence of bowel sounds and the condition of the surgical site are vital pieces of information that need to be communicated to ensure continuity of care and to monitor for complications such as paralytic ileus or infection.

A. Emphasize that using safe sex practices removes the risk of STIs. B. Clarify that all STIs are transmitted through sexual intercourse. C. Explain that reinfections occur from sex with untreated partners. D. Provide counseling that most contraceptives protect against infection.

Correct Answer is C

Explanation

A. While safe sex practices significantly reduce the risk of STIs, they do not eliminate it entirely; thus, this statement is misleading.

B. Not all STIs are transmitted solely through sexual intercourse (e.g., some can be transmitted through non-sexual contact), making this statement too broad.

C. Explaining that reinfections occur from sexual contact with untreated partners is accurate and emphasizes the importance of treatment for both the infected person and their partners.

D. While some contraceptives may provide a barrier to STIs, not all methods are effective against infections, so this statement requires clarification.

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Exhibits The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

Correct Answer is C

Explanation

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Exhibits

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.