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 D
Explanation
This is the best intervention for the PN to implement because it monitors the client's fluid status and helps detect fluid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.
Correct Answer is A
Explanation
Rationale for A: Elevated energy level is a common effect of cocaine use, but it does not encompass the full range of behaviors associated with the drug's effects.
Rationale for B: Powerful cravings for more cocaine can develop over time, especially after the initial effects wear off, but they are not the immediate behavior observed.
Rationale for C: High self-esteem may be a temporary effect, but it does not specifically indicate current behavior associated with cocaine use.
Rationale for D: Euphoria is one of the primary effects of cocaine and is typically experienced shortly after use. This intense feeling of pleasure is a hallmark behavior observed in clients who have recently used cocaine.
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