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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

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice C rationale

In a hurricane disaster medical area, drinking water contaminated by sewage is a common source of contamination that could lead to diarrhea. Hurricanes and severe storms often result in flooding, which can contaminate drinking water supplies with sewage and other pollutants. This can lead to the spread of waterborne diseases, including those that cause diarrhea. Type 2 diabetes Explore

A. Remove resuscitation equipment from the room. B. Place a small pillow under the head. C. Take out dentures and place in a labeled cup. D. Apply a body shroud. E. Gently close the eyes.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Removing resuscitation equipment from the room is a standard practice before allowing family members to view the body after an unsuccessful resuscitation. This helps to create a more peaceful and less distressing environment for the family. It also respects the dignity of the deceased and allows the family to focus on their loved one, rather than the medical interventions that were attempted.

Choice B rationale

Placing a small pillow under the head is a common practice in preparing the body for viewing by the family. This helps to position the body in a natural and peaceful manner, which can be comforting for the family. It also respects the dignity of the deceased.

Choice E rationale

Gently closing the eyes is another common practice in preparing the body for viewing by the family. This helps to give the appearance of peaceful rest, which can be comforting for the family. It also respects the dignity of the deceased.

Choice C rationale

Taking out dentures and placing them in a labeled cup is not a standard practice in preparing the body for viewing by the family. Dentures, if present, are usually left in place to maintain the natural appearance of the face.

Choice D rationale

Applying a body shroud is not a common practice in preparing the body for viewing by the family. The use of a body shroud may vary based on cultural or religious preferences, but it is not a standard procedure in many healthcare settings.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea.Which source of contamination should the nurse consider when interviewing the client about exposure?

Correct Answer is C

Explanation

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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