Patient Data

Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen.

Which action(s) should the nurse take next? Select all that apply.

Administer additional nebulizer treatment as ordered.

Take and monitor vital signs.

Apply a nonrebreather oxygen mask.

Increase oxygen flow.

Raise the head of the bed.

Provide client incentive spirometer and instruct on use.

Answer and Explanation

Correct Answer : A,B,D,E

Inhaled short acting beta agonists can should be administered up to 3 times until there the obstruction in managed. In the event that the nebulization fails to relieve the respiratory distress, other treatment options such as magnesium sulphate can be used.

Oxygen flow should also be titrated appropriately to achieve the targeted SPO2 levels. However, changing the modality of oxygen delivery is not necessary at this part.

Continuous vital signs monitoring allows for timely interventions at all times to prevent respiratory failure. Although not a primary measure, raising the head of the bed can increase comfort reducing the work of breathing.

While incentive spirometry may have a role in the management of asthma in certain situations, such as during the recovery phase after an acute exacerbation or in individuals with chronic asthma who have reduced lung function, it is not typically used as a primary intervention during the acute phase of an asthma attack.

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

Explanation

A. Shrimpisknown to be high in purines and is generally not recommended for a gout-friendly diet

B. Sardines are high in purines, which can increase uric acid levels in the body and contribute to gout flare-ups. Foods high in purines should generally be limited in the diet of someone with gout.

G. Liver is very high in purines and can significantly elevate uric acid levels. Consumption of liver and other organ meats should be minimized or avoided by individuals with gout to help prevent gout attacks.

Other foods are low in purine and hence not contraindicated in clients with gouty arthritis.

A. Select another finger. B. Assess radial pulse volume. C. Collect the blood sample. D. Apply pressure to the site.

Correct Answer is D

Explanation

D. Applying pressure to the site helps to reduce engorgement and promote normal blood flow. This action can help alleviate the localized congestion and ensure a more accurate fingerstick glucose measurement. Once the pressure is applied and the congestion subsides, the nurse can proceed with collecting the blood sample.
A. While selecting another finger may be considered if the initial fingerstick attempt was unsuccessful or if the fingertip is excessively traumatized, it may not be necessary if the observation of redness and engorgement can be addressed with appropriate pressure application to the site.
B. Assessing radial pulse volume is not directly relevant to addressing the observed redness and engorgement of the fingertip after milking. This action is more appropriate for evaluating peripheral circulation and arterial perfusion in other clinical contexts
C. Collecting the blood sample without addressing the observed redness and engorgement of the fingertip may result in a suboptimal sample quality and could cause discomfort or further tissue trauma to the client.

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Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient’s Data Exhibits Select the 3 dietary choices that are not part of the recommended diet gout.

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

Explanation

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

Correct Answer is D

Explanation

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?

Patient Data Exhibits For each medication used to treat gout, choose the most likely therapeutic outcome and the teaching associated with the medication.

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Patient Data

Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen.

Which action(s) should the nurse take next? Select all that apply.