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 ["0.4"]
Explanation
To determine the correct dosage, the nurse needs to perform a calculation using the information provided. The prescription is for 200,000 units of penicillin, and the available vial concentration is 500,000 units per mL.
To find out how many mLs to administer, the nurse would divide the prescribed units by the concentration of units per mL. This is calculated as 200,000 units divided by 500,000 units/mL, which equals 0.4 mL.
Correct Answer is A
Explanation
A. Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
B. Providing frequent mouth care is important for oral hygiene but may not be as critical as ensuring a patent airway during seizures.
C. Keeping the room at a comfortable temperature is important for overall comfort but is not the most essential intervention during seizure activity.
D. Maintaining the client in a semi-Fowler's position may help with ventilation and drainage but is not as crucial as ensuring airway patency.
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