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Patient Data.

Exhibits

Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize

as the priority problem for this client, as evidenced by the client's statement, .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

The rationale for selecting impaired gas exchange is based on the clinical manifestations presented by the client. The client's difficulty in breathing, the need to pause to catch breath, the ineffectiveness of the rescue inhaler, and the expressed feeling of nervousness during episodes are indicative of a compromised gas exchange. This is further supported by the objective data: an oxygen saturation of 88% on room air is below normal levels, suggesting that the client is not receiving adequate oxygen. Expiratory wheezes indicate an obstruction of airflow, commonly seen in asthma attacks, which can impair gas exchange. Therefore, the nurse's assessment and the client's symptoms align with the diagnosis of impaired gas exchange, necessitating immediate intervention to improve the client's respiratory function.


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Related Questions

Correct Answer is D

Explanation

A. Muscle atrophy may indicate various underlying conditions but is not typically associated with an exacerbation of SLE. While it should be noted, it is not the most critical finding to report in this context.

B. Low-grade fever is a common symptom of SLE exacerbation and may not require immediate reporting unless accompanied by other concerning symptoms.

C. Joint pain is a hallmark symptom of SLE exacerbation but may not warrant immediate reporting unless it is severe or debilitating.

D. Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.

Correct Answer is A

Explanation

A. Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is essential in the immediate management of a client with sudden, severe headache and neurological deficits suggestive of stroke. Time- sensitive interventions, such as IV fibrinolytic therapy, may be indicated if the client meets criteria for treatment.

B. Administering aspirin to prevent further clot formation and platelet clumping is contraindicated in the acute management of a suspected stroke until hemorrhagic stroke is ruled out.

C. Verifying prescribed laboratory tests include prothrombin time and platelet count is important for assessing coagulation status, but it is not the immediate intervention needed in this situation.

D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority intervention in the acute management of a suspected stroke.

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