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Exhibits

The nurse reviews the client's history of the presenting illness in the electronic medical record. Highlight the pieces of key subjective data which indicate the client is in need of health interventions.

A 34-year-old male client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park. The client is able to answer questions every few words to catch his breath. He reports using his rescue inhaler three times, but he couldn't catch his breath. He reports that his symptoms are worse when outdoors and when exercising, and episodes like this make him extremely nervous. He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working.

an asthma attack that began after jogging through a local park

able to answer questions every few words to catch his breath

reports using his rescue inhaler three times, but he couldn't catch his breath

symptoms are worse when outdoors

episodes like this make him extremely nervous

came to the ED today because he noticed his inhaler was expired

Answer and Explanation

The Correct Answer is ["B","C","F"]

Rationale for correct answers:

"The client is able to answer questions every few words to catch his breath."
- Indicates severe shortness of breath, which requires immediate medical attention.
"He reports using his rescue inhaler three times, but he couldn't catch his breath."
- Demonstrates that his asthma attack is not responding to usual interventions, indicating the need for additional or advanced treatment.
"He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working."
- Highlights a lapse in medication management (expired inhaler), suggesting the need for health education and prescription renewal.

Rationale for incorrect answers:

"Episodes like this make him extremely nervous."
- While anxiety is relevant, it is a secondary issue compared to the physiological needs in this situation.
"The client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park."
- The activity triggering the attack (jogging) is not an immediate factor needing intervention but rather an avoidable trigger to address long-term.
"He reports that his symptoms are worse when outdoors and when exercising."
- While important for identifying triggers, this is not an immediate priority for intervention in the emergency setting.

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Free Nursing Study Resources

Correct Answer is ["56"]

Explanation

Step-by-Step Calculation:

Step 1: Convert liters to milliliters (mL) 2 liters × 1000 mL per liter = 2000 mL

Step 2: Calculate the total number of drops to be infused 2000 mL × 20 gtt per mL = 40000 gtt

Step 3: Convert hours to minutes 12 hours × 60 minutes per hour = 720 minutes

Step 4: Calculate the drops per minute 40000 gtt ÷ 720 minutes = 55.56

Step 5: Round to the nearest whole number 56 gtt/min

Answer: 56 gtt/min

A. Increased oral fluid intake B. Restriction of caloric intake C. Higher doses of insulin D. Fewer fingerstick glucose checks

Correct Answer is C

Explanation

Choice A reason: Increased oral fluid intake is a general recommendation for clients with an infection to prevent dehydration and help thin respiratory secretions. While staying hydrated is important, it is not a specific change in blood glucose management for a client with diabetes and an upper respiratory infection.

Choice B reason: Restriction of caloric intake is not appropriate advice for a client with diabetes and an infection. During illness, the body’s metabolic needs increase, and caloric intake should be adjusted to meet these needs. Restricting calories can lead to inadequate nutrition and further complications.

Choice C reason: Higher doses of insulin are often needed for clients with diabetes who are experiencing an infection. Infections can cause increased stress on the body, leading to elevated blood glucose levels. The body’s inflammatory response and the release of stress hormones can result in insulin resistance and higher blood sugar levels. Therefore, it is common for healthcare providers to adjust insulin doses upward to manage these changes and maintain glycemic control during periods of illness.

Choice D reason: Fewer fingerstick glucose checks are not recommended. In fact, during illness, it is crucial for clients with diabetes to monitor their blood glucose levels more frequently. Close monitoring helps to detect hyperglycemia or hypoglycemia and allows for timely adjustments in insulin or other diabetes medications. Frequent glucose checks are essential for managing blood sugar levels effectively during illness.

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Naxlex Comprehensive Predictor Exams

A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["56"]

Explanation

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?

Correct Answer is C

Explanation

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