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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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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

  1. Blood pressure 130/86 mm Hg
    • Neither Disease Process Nor Medication: This blood pressure reading is within the normal range for an adult and does not indicate a specific disease process or medication effect.
  2. Temperature 98.9° F (37.1° C)
    • Neither Disease Process Nor Medication: This temperature is within the normal range and does not indicate a specific disease process or medication effect.
  3. Oxygen saturation 88% on room air
    • Disease Process: This low oxygen saturation level is likely due to the acute asthma attack, which is a disease process affecting the client's ability to oxygenate properly.

Correct Answer is ["A","D","E"]

Explanation

A. Administer medications as prescribed. This includes the albuterol/ipratropium nebulizer treatment and oral prednisone, which are essential for managing acute asthma exacerbations.

B. Ask the client for a list of current medications: While this information is important, it is not the immediate priority in managing an acute asthma exacerbation.

C. Notify the healthcare provider of the client's need for intubation: Intubation is a more invasive procedure and is typically reserved for severe cases of respiratory distress that are not responding to medical therapy. In this case, the client's condition is not severe enough to warrant immediate intubation.

D. Apply oxygen via nasal cannula. The client's oxygen saturation is below 94%, indicating hypoxemia, and supplemental oxygen is necessary to improve oxygenation.

E. Provide client teaching. This includes educating the client about asthma triggers, medication adherence, and early signs of an asthma exacerbation.

F. Place the client in Trendelenburg position: This position is not indicated for asthma exacerbations. It is typically used for conditions like shock or hypotension.

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