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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Left-sided heart failure involves the failure of the left ventricle to pump blood efficiently into systemic circulation. Knowledge of hemodynamics must be applied to differentiate between backward failure, causing pulmonary congestion, and forward failure, which results in decreased cardiac output and systemic tissue hypoperfusion.

Choice A rationale: Jugular vein distension is a clinical hallmark of right-sided heart failure. It occurs when the right ventricle fails to pump blood into the lungs, causing increased pressure to back up into the superior vena cava and the systemic venous circulation.

Choice B rationale: Lower extremity edema, specifically dependent pitting edema, is characteristic of right ventricular dysfunction. When the right heart fails, systemic venous pressure rises, forcing fluid into the interstitial spaces of the ankles and feet due to increased hydrostatic pressure in the peripheral veins.

Choice C rationale: Hepatomegaly, or liver enlargement, results from systemic venous congestion associated with right-sided heart failure. Increased pressure in the hepatic veins causes the liver to become engorged with blood, a condition often accompanied by right upper quadrant abdominal discomfort and splenomegaly.

Choice D rationale: Fatigue is a primary symptom of left ventricular dysfunction caused by decreased cardiac output. As the left ventricle fails to eject sufficient oxygenated blood to meet metabolic demands, skeletal muscles and vital organs receive inadequate perfusion, leading to profound physical exhaustion.

A. Take the client to the emergency department (ED) B. Apply the client's home oxygen C. Ensure that the client avoids salt intake for the rest of the day D. Check for a thrill and bruit at the client's dialysis access site

Correct Answer is A

Explanation

Choice A reason: Taking the client to the emergency department is crucial because missing a dialysis session can lead to severe complications such as fluid overload, high potassium levels, and other electrolyte imbalances. These conditions can be life-threatening and require immediate medical attention to stabilize the client.

Choice B reason: Applying home oxygen is not the most critical intervention in this scenario. While oxygen therapy might be necessary in some cases, it does not address the immediate risk of complications arising from missed dialysis.

Choice C reason: Ensuring that the client avoids salt intake for the rest of the day is important for managing fluid balance, but it is not the most urgent action needed in this situation. The client's lethargy and difficulty arousing indicate a more serious underlying issue that requires immediate medical evaluation.

Choice D reason: Checking for a thrill and bruit at the client's dialysis access site is important for assessing the patency of the access site, but it is not the most critical action in this scenario. The immediate concern is the client's lethargy and potential complications from missed dialysis, which necessitate emergency medical care.

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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.

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Naxlex Comprehensive Predictor Exams

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

Correct Answer is D

Explanation

A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

Correct Answer is A

Explanation

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing fluid intake, the nurse should include which type of fluid limitation?

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The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect?

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.