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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 ["A","B"]

Explanation

In the provided scenario, the two key pieces of subjective data indicating the need for health interventions are the client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise. These details suggest that the client's asthma is not well-controlled, and the ineffectiveness of the rescue medication, especially with an expired inhaler, warrants immediate medical attention.

Correct Answer is B

Explanation

A. Administer IV fluid bolus as prescribed by the healthcare provider is not the priority unless there is evidence of hypovolemia or shock, which isn't indicated by the current vital signs alone.

B. Medicate for pain and monitor vital signs according to protocol is the most important intervention. The client's elevated heart rate, respiratory rate, and blood pressure are likely due to inadequate pain control following a thoracotomy, a major surgical procedure known for causing significant postoperative pain. Managing the pain is crucial because uncontrolled pain can lead to increased sympathetic nervous system activity, resulting in tachycardia, hypertension, and tachypnea. Addressing the pain effectively will help stabilize these vital signs.

C. Encourage the client to splint the incision with a pillow to cough and deep breathe is an important postoperative intervention to prevent complications such as atelectasis, but it should be done after pain is adequately controlled, as pain can inhibit the ability to deep breathe and cough effectively.

D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter may be necessary if there are signs of hypoxia. However, the vital sign changes here are more likely related to pain rather than respiratory distress, making pain management the immediate priority.

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