Patient Data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Anthrax

The client's flu-like symptoms followed by shortness of breath, cough, and chest pain align with potential inhalation anthrax. Furthermore, working in a government building and opening a suspicious package containing white powder suggests potential exposure to anthrax spores.
Actions to Take:

Place the client in isolation - Isolating the client helps prevent potential transmission of anthrax to others.
Apply oxygen via nasal cannula: The client's low oxygen saturation (88%) necessitates oxygen therapy to improve oxygen delivery to tissues.

Parameters to Monitor:

Arterial blood gases - Monitoring arterial blood gases helps assess the client's respiratory status and oxygenation levels, which may be compromised in anthrax-related respiratory distress.
Breath sounds - Monitoring breath sounds helps assess the effectiveness of respiratory interventions and detect any changes indicative of worsening respiratory status.

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Correct Answer is D

Explanation

A. While monitoring troponin levels is important for diagnosing myocardial infarction, immediate relief of chest pressure and shortness of breath is a higher priority.
B. Placing an indwelling urinary catheter and measuring intake and output is not the immediate priority for managing acute chest pain and potential myocardial ischemia.
C. Counting premature ventricular contractions is useful but not the most immediate action in managing acute chest pressure and shortness of breath.
D. Recording the pain score and administering sublingual nitroglycerine addresses the acute symptoms of chest pressure and shortness of breath, aiming to relieve myocardial ischemia.

A. Urinary output. B. Serum electrolytes. C. Peristomal skin integrity. D. Skin turgor.

Correct Answer is B

Explanation

A. While monitoring urinary output is important, it is not the most critical assessment in this context.
B. Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C. Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D. Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.

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Patient Data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

Correct Answer is D

Explanation

Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

Correct Answer is B

Explanation

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Patient Data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

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Patient Data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.