Patient Data

Exhibits

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

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. Pins or wires are often inserted into the bone to apply traction, and these insertion sites provide a potential route for infection. The nurse should assess the pin sites regularly for signs of infection, such as redness, swelling, warmth, or drainage. Early detection and treatment of pin site infections help prevent the spread of infection and promote healing.
A. Administer pain medication at designated intervals around the clock:
While pain management is important for a client with a fracture, the primary intervention for skeletal traction is not necessarily related to pain medication administration.
B. Assessing pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this intervention is more relevant to vascular assessment and may not be directly related to skeletal traction.
C. Skeletal traction is typically maintained continuously to provide consistent traction and promote proper alignment of the fractured bone. Removing traction every shift would disrupt the therapeutic effect and delay healing.

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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Patient Data Exhibits 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

Correct Answer is D

Explanation

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

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?

A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?

Patient Data

Exhibits

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.