Patient Data.
Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","F"]
Explanation
A. The patient’s oxygen saturation remains below the target of 94% despite initial oxygen therapy. Therefore, increasing the oxygen flow might be necessary to achieve better oxygenation.
B. Since the patient remains symptomatic with ongoing wheezes, administering another dose of the nebulizer treatment as ordered, since the prescription included PRN can help to further open the airways and alleviate wheezing.
C. Elevating the head of the bed can help improve lung expansion and ease the work of breathing, which is particularly beneficial in respiratory distress situations.
D. Switching to a nonrebreather mask may be appropriate if the patient’s oxygen saturation does not improve sufficiently with the current method of oxygen delivery. This type of mask can deliver a higher concentration of oxygen.
E. While incentive spirometry is generally used for preventing pulmonary complications (such as pneumonia or atelectasis) after surgery or in conditions where patients are likely to be immobile, it may not be immediately beneficial or a priority in the acute management of an asthma attack. The primary focus should be on stabilizing the patient’s respiratory status through medication and oxygen therapy. Thus, this option is less critical at this stage.
F. Continuous monitoring of vital signs is crucial in acute cases like this to assess the patient's response to interventions and detect any deterioration in the clinical status.
Correct Answer is B
Explanation
A. Alternating IV and IM analgesic medications may be appropriate for pain management in some situations but is not the best initial intervention for continuous, severe pain in a client with stage IV bone cancer.
B. Administering opioid and non-opioid medication simultaneously is an appropriate intervention for managing severe pain, as it addresses pain from multiple pathways and may provide more effective pain relief.
C. Giving maximum dosage when the pain score reaches 10 is not recommended, as it may lead to overmedication and increased risk of adverse effects. Pain management should be based on the client's reported pain intensity and individualized needs.
D. Educating the client on signs and symptoms of narcotic dependency is important but is not the priority intervention in this situation. Pain management and relief should be the immediate focus for the client's comfort and quality of life.
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