Exhibits

The nurse has completed a client history and initial assessment and is now planning and prioritizing care of the client.

Complete the following sentences by choosing from the lists of corresponding options.

Based on history and assessment data, the nurse should prioritize
_
as the priority problem for this client, as evidenced by the client’s statement
_

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Based on history and assessment data, the nurse should prioritize activity intolerance as the priority problem for this client, as evidenced by the client's statement "I just can't catch my breath."

Rationale:

Activity intolerance: The client's shortness of breath and wheezing indicate impaired gas exchange and reduced oxygenation, which limits their ability to engage in physical activity.
Anxiety: While anxiety can exacerbate asthma symptoms, the immediate priority is to address the physiological issue of impaired gas exchange.

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Correct Answer is A

Explanation

A. Acute pain is the most immediate and pressing problem for the client, given the reported severe flank pain. Managing pain effectively is a primary concern in nursing care, particularly for clients with renal calculi.

B. While impaired renal function is a concern with renal calculi, the acute pain takes precedence as it requires immediate intervention to enhance the client's comfort and promote better overall health.

C. The risk for aspiration is a potential issue due to nausea and vomiting; however, addressing the pain is more urgent in this scenario.

D. Nutritional deficit related to nausea is also a valid concern but is secondary to the acute pain management. The client’s immediate comfort and pain relief should be prioritized to facilitate recovery and improve overall well-being.

A. Elevated creatinine and blood urea nitrogen (BUN). B. Hypovolemia and electrocardiographic (ECG) changes. C. Uremic irritation of mucous membranes and skin surfaces. D. Side effects of total parenteral nutrition (TPN) and intralipids.

Correct Answer is B

Explanation

A. While elevated creatinine and BUN are important indicators of kidney function, in the diuretic phase, the focus shifts to monitoring for complications, particularly fluid and electrolyte balance.

B. Hypovolemia can occur due to excessive diuresis during the diuretic phase, which can lead to significant cardiovascular effects, including ECG changes related to electrolyte imbalances, particularly potassium levels.

C. Monitoring for uremic irritation is important but less critical than monitoring for hypovolemia and ECG changes that can lead to acute complications.

D. While monitoring for side effects of TPN is relevant, it is not the priority in the context of AKI transitioning phases where fluid and electrolyte balance are paramount.

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Naxlex Comprehensive Predictor Exams

A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

Correct Answer is A

Explanation

A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

Correct Answer is B

Explanation

Exhibits The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one answer selected.

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?

Exhibits The nurse is reviewing the client's dietary choices for opportunities to promote better outcomes by limiting gout attacks. Select the 3 dietary choices that are not part of the recommended diet for a client with gout.

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?