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.
Blood pressure 122/84 mmHg
Heart rate 105 beats/minute
Client can now speak in full sentences without pausing.
Respirations 16 breaths/minute
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}
Indicates the Interventions Were Successful:
- Client can now speak in full sentences without pausing. This shows an improvement in the client's breathing and overall respiratory function.
- Respirations 16 breaths/minute. This is a normal respiratory rate, indicating that the client's breathing has stabilized.
No Indication that the Interventions Were Successful:
- Blood pressure 122/84 mmHg. While this is a normal blood pressure reading, it does not specifically indicate the success of the interventions for an asthma attack.
- Heart rate 105 beats/minute. Although slightly improved, this heart rate is still elevated and does not clearly indicate the success of the interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
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.
Correct Answer is B
Explanation
A. Eating a protein snack before exercising can help prevent hypoglycemia, but this may not be necessary for every individual and does not address the overall management of diabetes.
B. Understanding the importance of receiving an influenza vaccine annually is crucial for clients with diabetes, as they are at higher risk for complications from influenza and other infections.
C. While it is important to monitor alcohol consumption, the statement may not indicate full understanding of how alcohol can affect blood glucose levels and the potential need for individualized guidance.
D. While using salt, herbs, and spices can enhance food flavor, it does not specifically address diabetes management, particularly regarding sodium intake for individuals at risk for hypertension.
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