Patient Data

Exhibits

The nurse performs an initial focused assessment of the client.

Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

Blood pressure 130/86 mmHg

Respirations 28 breaths/minute

Temperature 98.9" F (37.1°C)

Heart rate 112 beats/minute

Oxygen saturation 88% on room air

Answer and Explanation

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

In an asthmatic attack, exposure to triggers leads to bronchospasm which blocks airflow leading to impaired ventilation that manifests as respiratory distress- tachypnea. This prevents oxygenation with resultant hypoxia as evidenced by low SPO2 levels. Continuous use of a non- selective beta agonists leads to elevated heart rate.

Acute asthmatic attacks are not associated with changes in blood pressure

Acute asthmatic attacks are not associated with changes in temperature. However, when triggered by pulmonary infections, the client may experience episodes of fever.

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Correct Answer is B

Explanation

B. Dietary intake plays a significant role in the management of chronic pancreatitis pain. Certain foods, especially those high in fat, can exacerbate symptoms and trigger pain episodes in clients with pancreatitis.
A. While assessing the activity level of bowel sounds is important for monitoring gastrointestinal function, it is not the most crucial assessment data in this scenario. Bowel sounds may be decreased or absent in clients with severe abdominal pain, but addressing the dietary triggers of chronic pancreatitis pain takes priority.
C. Assessing the level and amount of physical activity is important for overall health and may play a role in managing chronic pancreatitis. However, in the context of persistent gnawing abdominal pain, addressing dietary factors that exacerbate the pain is more immediate and crucial.
D. Assessing the color and consistency of feces is important for monitoring gastrointestinal function and identifying signs of malabsorption or steatorrhea, which can occur in chronic pancreatitis. However, in the context of persistent gnawing abdominal pain, assessing dietary intake and potential triggers of pain is more pertinent to pain management.

A. Remove the medication from the dispensing system. B. Compare the client’s wristband to the medication administration record. C. Document administration of the medication. D. Open the medication package. E. Obtain the client’s apical heart rate.

Correct Answer is E, A, B, D, C

Explanation

Before administering digoxin, the nurse should check the patient's apical heart rate. If the heart rate is below 60 beats per minute for an adult, or below the prescribed limit for a child, the nurse should hold the medication and notify the healthcare provider. This is the first step because the nurse needs to have the medication in hand before proceeding with the other steps. This step is crucial to ensure that the right medication is being given to the right patient. It's a part of the "five rights" of medication administration: right patient, right medication, right dose, right route, and right time. Once the nurse has confirmed the patient's identity and heart rate, the next step is to open the medication package. After administering the medication, the nurse should document it in the patient's medical record. This is important for maintaining an accurate record of the patient's medication history.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

Correct Answer is B

Explanation

A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Correct Answer is E, A, B, D, C

Explanation

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

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?

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?