Exhibits
The nurse has completed a client history and initial assessment and is now planning on prioritizing care of the client.
Complete the following sentences by choosing from the list of corresponding options
Based on the history and assessment data, the nurse should prioritize
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for Correct Choices
Option 1: Impaired gas exchange is the priority problem because the client's oxygen saturation is critically low at 88%, and the assessment reveals expiratory wheezes, rapid respirations (28/min), and severe shortness of breath. These indicate difficulty in maintaining adequate oxygenation.
Option 2: "I used my rescue inhaler three times, but I couldn’t catch my breath." This statement directly indicates that the asthma attack is unresponsive to the usual medication, highlighting the severity of the impaired gas exchange.
Rationale for Incorrect Choices
Option 1:
A. Anxiety: While anxiety may be present, it is a secondary issue caused by the asthma attack and is not the root cause of the client’s symptoms.
C. Ineffective airway clearance: Although wheezing suggests partial obstruction, the critical issue is the impaired oxygenation and low oxygen saturation rather than mucus or secretions obstructing the airway.
D. Activity intolerance: The client’s difficulty breathing is not primarily due to exertion but rather to the asthma attack itself.
Option 2:
A. "I was jogging when it started.": This identifies the trigger for the attack but does not explain the severity or lack of response to medication.
C. "My symptoms are worse when outdoors and when exercising.": This is helpful for identifying long-term triggers but does not prioritize the immediate issue of unrelieved shortness of breath.
D. "I noticed my inhaler was expired and was worried the medication was not working.": While this points to a lapse in medication management, it does not address the acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A reason: An exit site infection can occur around the catheter insertion site, leading to redness, tenderness, and drainage. While this is a concerning issue that needs to be addressed, the more significant complication to prevent is peritonitis, which can result from an exit site infection if it spreads.
Choice B reason: Peritonitis is a serious and potentially life-threatening infection of the peritoneal cavity. In clients on peritoneal dialysis, signs such as redness, tenderness, and drainage around the catheter site are alarming indicators that could lead to peritonitis if not promptly treated. Peritonitis can cause severe abdominal pain, fever, and cloudy dialysis fluid, and requires immediate medical intervention to prevent complications.
Choice C reason: Outflow obstruction is a complication where the peritoneal dialysis fluid does not drain properly. This can be caused by a number of issues including catheter malposition or blockages, but it is not directly related to the symptoms of redness, tenderness, and drainage at the catheter site. Outflow obstruction is important to monitor but does not represent the immediate risk that peritonitis does.
Choice D reason: Atelectasis refers to the collapse of a part or all of a lung, often due to blockage of the air passages. This is not related to the symptoms around the peritoneal dialysis catheter site. While respiratory issues must be monitored, the primary concern here is the potential for peritoneal infection.
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