Patient Data

Exhibits

The nurse has implemented additional needed actions.

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected.

Assessment Data: Indicates the Interventions Were Successful/ No Indication that the Interventions Were Successful

Heart Rate 105 beats/minute

Client can now speak in full sentences without pausing.

Lung sounds clear

Respirations 16 breaths/minute

Client reports, “It’s a lot easier to breathe now.”

Blood Pressure 122/84 mmHg

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Correct Answers:

Indicates the Interventions Were Successful: A, B, C, D, E, F

No Indication that the Interventions Were Successful: None

Rationale:

The assessment data provided indicates a positive response to the interventions for the asthma attack. The decrease in heart rate from 112 to 105 beats per minute, alongside the client's ability to speak in full sentences without pausing, suggests an improvement in respiratory function. Clear lung sounds and a reduction in respiratory rate to 16 breaths per minute further support this conclusion. The client's subjective report of eased breathing and the maintenance of blood pressure within normal limits post-intervention are also indicative of successful treatment. These observations collectively demonstrate the effectiveness of the administered medications and oxygen therapy in managing the acute asthma symptoms presented by the client.

Nursing Test Bank

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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.

A. Collect the blood sample. B. Select another finger. C. Apply pressure to the site. D. Assess radial pulse volume.

Correct Answer is B

Explanation

A. Collecting the blood sample from a reddened and engorged fingertip may lead to inaccurate glucose readings and can cause discomfort to the client. Selecting another finger is a more appropriate action.

B. Selecting another finger ensures an accurate blood sample and minimizes discomfort to the client. It allows for a fresh puncture site that is not engorged, improving the accuracy of the glucose reading.

C. Applying pressure to the site may temporarily reduce engorgement but may not be sufficient to obtain an accurate blood sample. Selecting another finger is a more appropriate action.

D. Assessing radial pulse volume is not necessary in this situation, as the client's fingertip appearance does not indicate compromise of peripheral circulation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

Correct Answer is B

Explanation

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