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","D","F"]

Explanation

A The use of short acting beta agonists and oral steroids is key during an asthmatic attack to prevent respiratory failure.
D The nurse should also rule out the use of medications such as beta blockers which may predispose to asthmatic attack due to bronchospasms.
F Oxygen therapy should be initiated to prevent hypoxemia due to impaired ventilation. At this point, intubation may not be necessary until first line interventions have been attempted.
B Client teaching on proper inhalation technique is key. The client should also be advised on avoidance of triggers to prevent recurrence of the asthmatic attack. This, however, should be done after the client is stabilized.

Incorrect;

The Trendelenburg position is not recommended. Instead, sitting upright or in a semi-upright position can help expand the chest and improve lung expansion. This position allows the diaphragm to move more freely and can facilitate easier breathing. Leaning forward slightly may also help reduce the feeling of chest tightness.

A. Palpate the right flank for tenderness. B. Evaluate the urine for a strong odor. C. Test the urine for the presence of hematuria. D. Measure the temperature and pulse rate.

Correct Answer is D

Explanation

D. In a client presenting with urinary symptoms and lower back pain, measuring the temperature and pulse rate is essential for assessing for signs of systemic infection, such as fever (elevated temperature) and tachycardia (elevated pulse rate). These vital signs can help determine the urgency of the situation and guide further assessment and management.
A. Palpating the right flank for tenderness may be appropriate to assess for signs of kidney involvement, such as in pyelonephritis. However, this intervention is not the first priority. Assessing for systemic signs of infection, such as fever, is more urgent.
B. Evaluating the urine for a strong odor may provide additional information about the student's symptoms, but it is not the first intervention priority.

C. Testing the urine for the presence of hematuria (blood in the urine) is an important diagnostic step in evaluating urinary symptoms, but it is not the first intervention priority. Hematuria may be present in various conditions, including UTIs, kidney stones, or other urinary tract disorders.

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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.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

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A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

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.