Find patient data below.
What actions should the nurse plan for the rest of the shift? Select all that apply.
Monitor the oxygen saturation
Discuss aggressive respiratory treatment options
Obtain a sputum culture
Allow the client to take a position of comfort
Discuss with the client potential asthma triggers
Consider positive pressure ventilation
Wean the supplemental oxygen
Prepare for deep tracheal suctioning
Correct Answer : A,D,E
A) Correct- Continuous monitoring of oxygen saturation ensures the client's oxygen levels remain within an acceptable range.
B) Incorrect - Discussing aggressive respiratory treatment options is not warranted based on the provided information. The current treatment plan includes appropriate interventions.
C) Incorrect - Obtaining a sputum culture is important for identifying infections, but it's not an immediate action in the context of the client's current symptoms.
D) Correct- Promoting comfort can help reduce anxiety and potentially improve breathing.
E) Correct- Educating the client about potential triggers supports better self-management.
F) Incorrect - Considering positive pressure ventilation is not indicated at this stage. The client's symptoms are being managed with other interventions.
G) Incorrect - Weaning supplemental oxygen is not mentioned in the patient data or nurses' notes as something that's currently necessary.
H) Incorrect - Preparing for deep tracheal suctioning is not warranted based on the patient data and the current treatment plan.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- Clients with Parkinson's disease often experience bradykinesia and impaired mobility. Rising slowly from a seated position is important to prevent falls and maintain stability. Affirming the correct movement strategy promotes the client's safety.
B) Incorrect- Telling the UAP to make the client move more quickly could be unsafe and not appropriate for a client with Parkinson's disease. Rapid movements might lead to balance issues or falls.
C) Incorrect- While demonstrating proper technique might be helpful, it's not the most immediate action the nurse should take. The client's safety and well-being are the priority.
D) Incorrect- Painful movement is not the primary issue here. The client's movement is slow due to Parkinson's disease, and this is expected.

Correct Answer is D
Explanation
A high blood urea nitrogen (BUN) level indicates impaired renal function, which can be caused by dehydration, infection, or nephrotoxic drugs. Chemotherapy can damage the kidneys and increase the risk of renal failure. The PN should report this finding to the charge nurse, as it may require fluid replacement, dose adjustment, or discontinuation of the chemotherapy.
The other options are not correct because:
- Periodic nausea and vomiting are common side effects of chemotherapy that can be managed with antiemetics, hydration, and dietary modifications. They are not as urgent as a high BUN level.
- Decreased deep tendon reflexes may indicate hypocalcemia, hypomagnesemia, or peripheral neuropathy, which can be caused by chemotherapy or other factors. They are not as urgent as a high BUN level.
- A platelet count of 135,000/mm3 or 135 x 10^9/L is slightly below the normal range, but not significantly low. Chemotherapy can cause thrombocytopenia, which increases the risk of bleeding. The PN should monitor the client for signs of bleeding, but this finding is not as urgent as a high BUN level.
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