Patient Data
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Methotrexate is commonly used in the treatment of rheumatoid arthritis (RA) to slow the progression of the disease by suppressing the immune system's response that causes inflammation. Aspirin may be used concurrently to provide symptomatic relief from pain and inflammation associated with RA.
B. While methotrexate may have side effects, its primary indication in RA treatment is to slow disease progression rather than to mitigate aspirin side effects.
C. Methotrexate and aspirin typically work through different mechanisms of action and are not typically used together to enhance each other's effectiveness.
D. Methotrexate and aspirin have different side effect profiles, but the primary reason for adding methotrexate is to slow the progression of RA rather than to replace aspirin due to side effects.
Correct Answer is D
Explanation
A. Using a large gauge IV catheter can increase the risk of bleeding in a thrombocytopenic patient.
B. Wrapping bruised areas with elastic bandage dressings is not recommended as wrapping bruised areas with elastic bandages can cause additional pressure and potentially worsen bruising or bleeding.
C. While dietary modifications may be necessary for other reasons, removing cold and frozen foods does not address the immediate risk of bleeding associated with low platelet counts.
D. This is crucial because patients with thrombocytopenia are at an increased risk of bleeding, which may not always be visible or apparent. Regular monitoring can help in early detection and prompt management of any bleeding episodes.
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