Exhibits
The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful. Each column must have at least one answer selected.
Client can now speak in full sentences without pausing
Respirations: 16 breaths per minute.
Blood pressure: 122/84 mmHg.
Client reports “It’s a lot easier to breathe now.”
Heart rate 105 beats/minute
Lung sounds clear
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}
Choice A reason: The client can now speak in full sentences without pausing, which indicates that the interventions were successful. This improvement suggests that the client's airways are less obstructed and he is able to breathe more easily. The ability to speak in full sentences is a key indicator of improved respiratory function and is often used as a measure of asthma control.
Choice B reason: Respirations at 16 breaths per minute indicate a successful intervention. This is within the normal range for adults and suggests that the client's breathing has stabilized. Before the intervention, the client’s respiratory rate was 28 breaths per minute, which is elevated and indicative of respiratory distress.
Choice C reason: Blood pressure at 122/84 mmHg does not indicate the success of the interventions. Blood pressure can be influenced by many factors and may not directly correlate with respiratory improvements. While the patient's blood pressure has decreased slightly, this change is not a definitive indicator of successful asthma treatment.
Choice D reason: The client reporting, "It’s a lot easier to breathe now," indicates successful interventions. This subjective report aligns with the clinical improvements observed in the client’s breathing and overall respiratory function. The client's perception of relief is an important aspect of assessing treatment efficacy.
Choice E reason: Heart rate at 105 beats per minute does not indicate the success of the interventions. Although the heart rate has decreased from 116 to 105 beats per minute, it is still elevated and may not directly reflect the improvement in respiratory status. Elevated heart rate could be due to anxiety or other factors unrelated to asthma management.
Choice F reason: Lung sounds being clear indicates successful interventions. Clear lung sounds suggest that the bronchospasm and airway obstruction have been relieved, which is a positive outcome of the administered medications and oxygen therapy. This objective finding is a strong indicator of improved respiratory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Obtaining a prostate-specific antigen (PSA) blood level test is important for screening and monitoring prostate health but does not directly reduce the risk factors for benign prostatic hyperplasia (BPH). PSA tests can help in early detection of prostate issues, but they are not preventive measures.
Choice B reason: Taking vitamin supplements is not specifically proven to reduce the risk of BPH. While maintaining overall nutritional health is important, there is no direct evidence that vitamin supplements alone can prevent BPH. It's better to focus on a balanced diet and healthy lifestyle choices.
Choice C reason: Consuming a high-protein diet does not specifically reduce the risk of BPH. While protein is an essential nutrient for overall health, there is no clear evidence that it has a direct impact on preventing BPH. A balanced diet that includes a variety of nutrients is more beneficial for general health and well-being.
Choice D reason: Increasing physical activity is one of the recommended lifestyle changes to reduce the risk of BPH. Regular physical activity can improve overall health, help maintain a healthy weight, and potentially reduce the risk of BPH. Physical activity is associated with better prostate health and can help mitigate some of the risk factors associated with BPH, such as obesity and sedentary lifestyle.
Correct Answer is C
Explanation
Choice A reason: A fasting serum glucose level of 140 mg/dL (7.77 mmol/L) indicates hyperglycemia, which is elevated but not an immediate life-threatening complication. It suggests poor blood glucose control but does not directly indicate a complication specific to type 2 diabetes and hypertension. This value should prompt further evaluation and adjustments in diabetes management, but it is not as critical as other potential findings.
Choice B reason: A glycosylated hemoglobin (A1c) level of 6.9% is within the range of good diabetic control. While it indicates the client has been managing their blood glucose levels relatively well over the past few months, it does not suggest a current complication. This value is used to assess long-term glucose control rather than acute issues.
Choice C reason: A serum creatinine level of 1.6 mg/dL (141.44 umol/L) is elevated and indicates impaired kidney function. Clients with type 2 diabetes mellitus and hypertension are at increased risk for kidney disease, known as diabetic nephropathy or hypertensive nephropathy. Elevated creatinine levels suggest that the kidneys are not filtering waste products effectively, which is a significant complication that requires immediate attention and intervention.
Choice D reason: A white blood cell (WBC) count of 11,000/mm3 (11 x 10^9/L) is slightly elevated and may suggest an infection or inflammation. However, it is not a specific complication related to type 2 diabetes mellitus and hypertension. Elevated WBC counts warrant further investigation to identify any underlying infection or inflammatory process, but it is not as directly related to diabetic or hypertensive complications as elevated serum creatinine.
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