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 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.
Correct Answer is A
Explanation
Choice A reason: Continuous cardiac monitoring is crucial for a client who has suffered an electrical injury. Electrical injuries can cause arrhythmias and other cardiac complications, which may not be immediately apparent. Continuous monitoring allows for the early detection and treatment of any cardiac abnormalities, which is vital for the patient's safety and recovery.
Choice B reason: Evaluating the level of consciousness is important for any patient, especially those with significant injuries, but it is not the most critical intervention in this scenario. While neurological assessments are part of comprehensive care, the immediate risk posed by cardiac complications from the electrical injury takes precedence.
Choice C reason: Performing passive range of motion exercises is beneficial for preventing contractures and maintaining joint mobility in immobile patients. However, it is not the most urgent intervention in the context of an electrical injury, where cardiac monitoring is paramount.
Choice D reason: Assessing lung sounds every 4 hours is a valuable part of monitoring for respiratory complications, particularly in burn patients. However, the immediate cardiac risks associated with electrical injuries necessitate continuous cardiac monitoring as the priority intervention.
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