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. Obtaining a keyboard designed to limit wrist flexion can help minimize exacerbation of symptoms associated with carpal tunnel syndrome and not Raynaud’s phenomena.

B. Maintaining warmth is crucial for individuals with Raynaud's phenomenon because it helps prevent the onset of symptoms triggered by cold exposure or stress.Keeping the body warm, especially the extremities, helps in minimizing these vasospastic attacks by ensuring that the blood vessels remain dilated, allowing for proper blood flow.

C. While adequate vitamin D intake is important for overall health, it is not specifically indicated as a management strategy for Raynaud's syndrome.

D. Keeping both hands elevated during work breaks may provide some relief, but it may not be practical or feasible for a data entry clerk to maintain this position consistently during work hours.

A. Auscultate the abdomen for bowel sound activity. B. Bring additional sterile dressing supplies to the room. C. Obtain a sample of the drainage to send to the laboratory. D. Prepare the client to return to the operating room.

Correct Answer is D

Explanation

A. Auscultating the abdomen for bowel sound activity is important, but the priority is addressing the dehisced and eviscerated wound.

B. Bringing additional sterile dressing supplies is a good idea, but the priority is addressing the dehisced and eviscerated wound.

C. Obtaining a sample of the drainage for laboratory analysis can wait until the client's immediate needs are addressed.

D. Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

Correct Answer is B

Explanation

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places It over the wound. Which intervention should the nurse implement next?

Correct Answer is D

Explanation

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