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Patient Data

History and Physical

The client is a 22-year-old female with a history of asthma. She was diagnosed at the age of 4 years old and has had 2 previous hospitalizations for asthma-related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week. She reports taking edible marijuana to relieve severe premenstrual symptoms. She came to the emergency department when she started having difficulty breathing on a hike. She took her usual dose of albuterol, but the symptoms did not resolve. The client’s friend called an ambulance when they noticed her distress.

Nurses’ Notes

The client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally.

Vital Signs

Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

Click to highlight the assessment findings that require immediate follow up by the nurse.

diagnosed at the age of 4 years old and has had 2 previous hospitalizations

reports taking edible marijuana

started having difficulty breathing on a hike

took her usual dose of albuterol, but the symptoms did not resolve

mild subcostal retractions

Wheezes are noted throughout the lung fields

client is pale

heart rate is 122 beats/minute

blood pressure 134/85 mm Hg

oxygen saturation 91% on room air

Answer and Explanation

The Correct Answer is ["C","D","E","F","G","H","J"]

Based on the provided information, the following assessment findings require immediate follow-up by the nurse:

Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
The client is pale: Paleness can be a sign of decreased oxygenation.
Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale

Sending wound drainage for culture and sensitivity is a key step in diagnosing and treating VRE. This can help determine the most effective antibiotic treatment20.

Choice B rationale

There is no specific “low bacteria diet” recommended for VRE infections20.

Choice C rationale

Standard precautions, including wearing a mask, are important for preventing the spread of VRE1617181920.

Choice D rationale

Contact precautions, such as wearing gloves and gowns, are recommended for staff and visitors to prevent the spread of VRE1617181920.

Choice E rationale

Monitoring the client’s white blood cell count can help assess the body’s response to the infection and the effectiveness of treatment20.

A. Increased pulse rate. B. Skin showing peripheral pallor. C. Clenched fists. D. Increased respiratory rate. E. Restlessness. F. Elevated temperature.

Correct Answer is ["A","C","D","E","F"]

Explanation

Choice A rationale

An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.

Choice B rationale

Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.

Choice C rationale

Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.

Choice D rationale

An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.

Choice E rationale

Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.

Choice F rationale

An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a possible vancomycin-resistant enterococci (VRE) infection is admitted with purulent drainage from an abdominal surgical incision.What nursing interventions should be included in the plan of care? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

Correct Answer is ["A","C","D","E","F"]

Explanation

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Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

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