Exhibits

The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.

Administer medications as prescribed.

Ask the client for a list of current medications.

Notify the healthcare provider of the client's need for intubation.

Apply oxygen via nasal cannula.

Provide client teaching.

Place the client in Trendelenburg position.

Answer and Explanation

Correct Answer : A,D,E

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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Correct Answer is D

Explanation

A. While bowel sounds can indicate gastrointestinal activity, they do not directly correlate with pain management or the underlying cause of abdominal discomfort in chronic pancreatitis.

B. The level and amount of physical activity may impact overall well-being but are less directly related to the management of abdominal pain from pancreatitis.

C. The color and consistency of feces can provide some information regarding pancreatic function and fat absorption but is not the most immediate factor affecting pain management.

D. Understanding the client’s eating patterns, including food triggers and timing, is crucial because certain foods can exacerbate abdominal pain in chronic pancreatitis. Dietary adjustments can significantly help manage symptoms and improve quality of life.

A. Assess the pulses proximal to the fracture site. B. Assess the pin sites for signs of infection. C. Administer pain medication at designated intervals around the clock. D. Remove traction every shift and provide skin care.

Correct Answer is A

Explanation

A. Assessing the pulses proximal to the fracture site is crucial for evaluating blood circulation to the affected limb and detecting potential complications such as compartment syndrome.

B. While monitoring pin sites for signs of infection is important, the priority is ensuring adequate circulation.

C. Administering pain medication is essential for comfort but does not address potential complications from skeletal traction.

D. Removing traction every shift is not advisable as it can compromise the alignment and healing of the fracture.

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Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

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A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?

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

Exhibits

The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.