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 C

Explanation

Choice A reason: Encouraging deep breathing and coughing exercises is generally important postoperatively to prevent respiratory complications. However, it is not specific to eye surgery and does not address the immediate care needs following the removal of glass from the eye.

Choice B reason: Obtaining vital signs every 2 hours during hospitalization is a standard postoperative procedure to monitor for complications. While important, it is not an intervention specific to eye surgery and does not directly address the protection and care of the operated eye.

Choice C reason: Providing an eye shield to be worn while sleeping is a crucial intervention immediately following eye surgery. The eye shield protects the operated eye from accidental injury, rubbing, or pressure during sleep. This helps to prevent complications and promotes healing by keeping the eye safe from potential harm while the client is unaware.

Choice D reason: Teaching a family member to administer eye drops is important for ongoing postoperative care. However, it is not the immediate priority following the surgery. The first step is to ensure the protection of the eye, which can be achieved by providing an eye shield. Teaching about eye drop administration can be done later as part of the discharge instructions.

A. Encourage the client to lie down and rest after meals B. Remind the client to avoid high-fiber foods C. Teach the client to elevate the head of the bed on blocks D. Instruct the client to use antacids only as a last resort

Correct Answer is C

Explanation

Choice A reason: Encouraging the client to lie down and rest after meals is not advisable for someone with gastroesophageal reflux. Lying down after eating can exacerbate symptoms by allowing stomach acid to more easily flow back into the esophagus. It's recommended that clients stay upright for at least 2-3 hours after meals.

Choice B reason: Avoiding high-fiber foods is not a standard recommendation for managing gastroesophageal reflux. In fact, a diet high in fiber can benefit overall digestive health and help prevent constipation. The key dietary advice usually involves avoiding trigger foods such as spicy, fatty, or acidic foods.

Choice C reason: Elevating the head of the bed on blocks is an effective way to manage gastroesophageal reflux, especially at night. This position helps keep stomach acid in the stomach and prevents it from flowing back into the esophagus, reducing symptoms such as heartburn.

Choice D reason: Instructing the client to use antacids only as a last resort is not necessarily accurate advice. While antacids can provide symptomatic relief, they are often used as part of a comprehensive management plan for gastroesophageal reflux. However, lifestyle modifications and dietary changes are also crucial.

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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

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

Correct Answer is C

Explanation

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?

Correct Answer is C

Explanation

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure:

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

A nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

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.