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 B

Explanation

A. Limiting oral fluid intake may be necessary in some cases of glomerulonephritis, especially if the client is experiencing edema or hypertension, but this is not a universal recommendation and should be assessed individually.

B. Restricting protein intake is important for clients with glomerulonephritis to reduce the workload on the kidneys and prevent further damage. This is a critical dietary adjustment that nurses should emphasize.

C. Increasing potassium-rich foods can be contraindicated in clients with glomerulonephritis, especially if renal function is compromised, as it can lead to hyperkalemia.

D. While high-fiber foods can be beneficial for overall health, they do not directly address the specific dietary needs of a client with glomerulonephritis in terms of protein and electrolyte balance.

A. Have the client sign the surgical and transfusion permits. B. Notify the healthcare provider of the client's medication history. C. Ensure that the potential for bleeding is explained to the client. D. Observe the heparin injection sites for signs of bruising.

Correct Answer is B

Explanation

A. While having the client sign permits is important, it is not the priority action in this situation.

B. Notifying the healthcare provider about the client's current heparin therapy is critical, as it may influence the timing of surgery and the risk of excessive bleeding during and after the procedure.

C. While explaining the potential for bleeding is important, it should occur after ensuring the surgical team is aware of the heparin use.

D. Observing injection sites for bruising is relevant but does not address the immediate concern regarding heparin use and potential bleeding during surgery.

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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 teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

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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.