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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Checking the blood pressure every five minutes for one hour is important, especially if the blood pressure is unstable. However, this action does not address the immediate issue of the client’s low temperature, which needs to be verified and addressed promptly to prevent complications such as hypothermia.

Choice B reason: Taking the client's temperature using another method is crucial. The extremely low tympanic temperature reading may not be accurate, and confirming the client's core body temperature is essential. Hypothermia can lead to serious complications, including altered cardiovascular and respiratory function, and needs to be managed promptly.

Choice C reason: Raising the head of the bed to 60 to 90 degrees is not appropriate in this situation. Elevating the head of the bed is typically done to improve respiratory function or decrease intracranial pressure, but it does not address the potential issue of hypothermia indicated by the low temperature reading.

Choice D reason: Asking the client to cough and deep breathe is a good practice to prevent postoperative complications such as atelectasis, but it is not the priority intervention in this scenario. The immediate concern is verifying the client's temperature to rule out or address hypothermia.

A. Infection prevention related to appendicitis B. Relief of acute pain C. Client education about diagnosis and plan of care D. Effective coping with illness-related anxiety E. Prevention of deep vein thrombosis related to immobility F. Promotion of bowel routine G. Fluid volume management

Correct Answer is ["A","B","C","D","G"]

Explanation

Choice A reason:

Infection prevention is crucial in managing appendicitis. Administering preoperative antibiotics, such as cefazolin, helps prevent surgical site infections and other complications. This aligns with standard care protocols for appendicitis patients.

Choice B reason:

Relieving acute pain is a priority in appendicitis care. Administering analgesics, including opioids, acetaminophen, and NSAIDs, effectively manages pain and reduces inflammation. Providing distraction techniques can also help alleviate discomfort until pain relief is achieved.

Choice C reason:

Client education about the diagnosis and plan of care is essential. Informing the patient about appendicitis, the surgical procedure, and postoperative expectations reduces anxiety and promotes cooperation. Effective communication enhances patient outcomes and satisfaction.

Choice D reason:

Effective coping with illness-related anxiety is important. Providing emotional support and addressing concerns can help the patient manage anxiety associated with the diagnosis and impending surgery. This approach contributes to overall well-being and recovery.

Choice G reason:

Fluid volume management is vital in appendicitis care. Administering intravenous fluids, such as Ringer's lactate, maintains hydration, supports renal function, and prepares the patient for surgery. Proper fluid balance is essential for optimal physiological function.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Exhibits The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

Correct Answer is ["A","B","C","D","G"]

Explanation

The healthcare provider prescribes 100 mL of 0.9% normal saline to be infused within 15 minutes. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

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 works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to wake during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUV

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

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.