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 D
Explanation
Choice A reason: Thick skin plaques topped by silvery white scales are characteristic findings in psoriasis vulgaris itself and do not indicate overexposure to PUVA treatment. These plaques are a result of rapid skin cell turnover and are typically the target of treatment, not a side effect of overexposure.
Choice B reason: The requirement for sunglasses because sunlight hurts the eyes is not a specific indication of overexposure to PUVA treatment. While PUVA therapy can increase sensitivity to light, the use of sunglasses is a preventive measure and does not necessarily indicate overexposure.
Choice C reason: Brown, rough, greasy, wart-like papules on the face suggest the presence of seborrheic keratosis or another benign skin condition, not overexposure to PUVA treatment. These lesions are unrelated to the therapy and do not serve as an indicator of overexposure.
Choice D reason: Tenderness upon palpation and generalized erythema are signs of overexposure to PUVA treatment. Overexposure can lead to phototoxic reactions, resulting in skin irritation, redness, and tenderness. These symptoms indicate that the client has received too much UV radiation during the treatment, leading to an adverse reaction.
Correct Answer is C
Explanation
Choice A reason: Central line insertion is not the appropriate intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates airway obstruction, which requires immediate airway management, not central venous access. Inserting a central line would not address the underlying issue of compromised airway patency, and it would delay necessary interventions to secure the airway.
Choice B reason: Nasogastric tube (NGT) insertion is not the correct intervention for stridor. NGT insertion is typically used for gastrointestinal decompression or feeding, not for managing airway obstruction. In the context of a client experiencing stridor, the priority is to ensure a patent airway, not to manage gastrointestinal issues. NGT insertion could potentially exacerbate airway compromise in a client with stridor.
Choice C reason: Tracheostomy placement is the correct intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates a potential airway obstruction, which can be life-threatening. A tracheostomy provides a secure airway and ensures adequate ventilation. This procedure is particularly important in cases where upper airway obstruction is suspected, such as swelling or hematoma formation following neck surgery.
Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction. The immediate concern for a client with stridor is ensuring a patent airway, and pacemaker placement would not resolve the airway compromise.
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