Patient Data
The nurse has identified the priority problem for the client and now must determine proper care interventions.
Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
Administer medications as ordered.
Provide client teaching.
Place the client in Trendelenburg position
Ask the client for a list of current medications.
Notify the healthcare provider of the client's need for intubation
Apply oxygen via nasal cannula
Correct Answer : A,B,D,F
A The use of short acting beta agonists and oral steroids is key during an asthmatic attack to prevent respiratory failure.
D The nurse should also rule out the use of medications such as beta blockers which may predispose to asthmatic attack due to bronchospasms.
F Oxygen therapy should be initiated to prevent hypoxemia due to impaired ventilation. At this point, intubation may not be necessary until first line interventions have been attempted.
B Client teaching on proper inhalation technique is key. The client should also be advised on avoidance of triggers to prevent recurrence of the asthmatic attack. This, however, should be done after the client is stabilized.
Incorrect;
The Trendelenburg position is not recommended. Instead, sitting upright or in a semi-upright position can help expand the chest and improve lung expansion. This position allows the diaphragm to move more freely and can facilitate easier breathing. Leaning forward slightly may also help reduce the feeling of chest tightness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Compromised peripheral arterial circulation can lead to decreased blood flow to the extremities, resulting in poor tissue perfusion. Over time, this can cause changes in the skin and hair distribution. Uneven hair distribution, or sparse hair growth, is a characteristic finding in areas of reduced arterial circulation due to inadequate oxygen and nutrient delivery to the hair follicles.
B. Lower leg edema is more commonly associated with compromised venous circulation rather than arterial circulation. It occurs due to impaired venous return, leading to fluid accumulation in the tissues.
C. Bronze pigmentation of the skin is not typically associated with compromised peripheral arterial circulation. Bronze pigmentation can occur in conditions such as hemochromatosis or Addison's disease but is not a specific sign of peripheral arterial disease.
D. In peripheral arterial disease, peripheral pulses may be diminished or absent due to arterial narrowing or occlusion. Bounding peripheral pulses are more commonly associated with conditions such as arterial hypertension.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Inflammation and discoloration are key symptoms of an acute gout attack.
- Inflammation: This occurs when urate crystals in the joints trigger an immune response, causing swelling, redness, warmth, and significant pain.
- Discoloration: Typically presents as redness over the affected joint, due to increased blood flow and inflammation, highlighting the body's response to the crystal deposits.
These symptoms help healthcare providers identify and treat gout, focusing on reducing inflammation and managing uric acid levels.
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