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Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Electrocardiogram: Tall T wave and widened QRS complex

Blood pressure: 126/76 mm Hg

Basilar crackles

Urine output: 20 mL in the last hour

Respirations: 26 breaths/minute

Heart rate: 72 beats/minute

Oxygen saturation 98% on room air

A normal body temperature (98.9°F or 37.1°C orally).

Answer and Explanation

Correct Answer : B,F,G,H

A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.

C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.

D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.

E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.

The assessment findings that suggest stabilization include:

A blood pressure within the normal range (126/76 mm Hg).

A heart rate within the normal range (72 beats/minute).

Oxygen saturation of 98% on room air, indicating adequate oxygenation.

A normal body temperature (98.9°F or 37.1°C orally).

These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Advising the mother that overuse of albuterol may cause chronic bronchitis is not accurate. Chronic bronchitis is a long-term condition primarily related to smoking or other irritants and is not typically associated with the appropriate use of albuterol as a bronchodilator.

B. Assuring the mother that she is using the medication correctly is not the best response, as it does not address the need for asthma management and education on the proper use of medications and when to seek medical attention.

C. Recommending that the mother bring the child in for immediate evaluation is not necessary if the child's asthma symptoms are being effectively managed with albuterol. However, the child should have an asthma action plan and regular follow-up with a healthcare provider for asthma management.

D Confirm that the medication helps to reduce airway inflammation.

Albuterol is a beta-adrenergic agonist bronchodilator commonly used in the treatment of asthma. It helps to open the airways by relaxing the smooth muscles in the bronchi, making it easier for the child to breathe during an asthma attack. Albuterol does not treat airway inflammation, but it is used to provide quick relief from bronchoconstriction.

The primary role of albuterol is to provide quick relief from acute bronchoconstriction during an asthma attack. It is not a medication for reducing airway inflammation, but it can be used in conjunction with other asthma medications that address inflammation, as prescribed by a healthcare provider. The nurse should educate the mother on the appropriate use of albuterol and the importance of asthma management under the guidance of a healthcare provider.

A. Dispose of the child's brushes, combs, and other hair accessories. B. Take the child to a hair salon for a shampoo and a shorter haircut. C. Wash the child's bed linens and clothing in hot soapy water. D. Rewash the child's hair following a 24-hour isolation period.

Correct Answer is C

Explanation

A. Disposing of the child's brushes, combs, and other hair accessories can be a good practice to prevent reinfestation, but it is not the primary instruction to provide in this case.

B. Taking the child to a hair salon for a shampoo and a shorter haircut is not a necessary or recommended treatment for head lice.

C. Wash the child's bed linens and clothing in hot soapy water.

When a child has head lice, it's important to take measures to prevent the spread of lice to others and to eliminate any potential sources of reinfestation. Washing the child's bed linens and clothing in hot, soapy water is an essential step in this process to kill any lice or nits (lice eggs) that may be present on these items.

D. Rewashing the child's hair following a 24-hour isolation period is not the standard approach for treating head lice with permethrin shampoo. It is important to follow the specific instructions provided with the product and to avoid overuse or misuse of the treatment.

The primary focus should be on treating the child's hair with the appropriate lice treatment (permethrin shampoo) as directed and taking preventive measures such as washing bed linens and clothing to reduce the risk of reinfestation.

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Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol. The child's mother tells the nurse that she uses this medication to open her son's airway when he is having trouble breathing. What is the nurse's best response?

Correct Answer is D

Explanation

A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin shampoo and calls his parents. Which instruction should the nurse provide to the parents about treatment for head lice?

Correct Answer is C

Explanation

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Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.